07080099CITY OF CUPERTINO
BUILDING DIVISION PERAM
rtlLMl I NV.
BUILDIpI,C�(�QQ(iFSS:MC CLELLAN RD ALLBRAND WINDOWS 07080099
OWNER'S NAME: PERivTrISSUE DATE
ADAM CABOT BLVD08/10/2007
PHONE: SANITARY NO. CONTROL NO.
ARCHn'ECT/ENGINEER:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
vith Section 7") of Division 3 of the Business and Professions Code, and my license is
n full force and effect. C� S
,icense Class C ( _;� Lic. A g
Sate n V 1 Q� Contraclnf N� p
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
-icensed Professional
OWNER -BUILDER DECLARATION
I hereby al -firm that I am exempt rmm the Contractor's License Law for the
-ollowing reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to cnnstrun, alter, improve, demolLsh, of repair any structure
irior to its issuance, also requires the applicant for such permit to rile a signed statement
,hat he is licensed pursuant to the provisions of the Contractor's Licensc Law (Chapter 9
;commencing with Section 7000) of Division 3 of the Business and Professions Code) or
chat he is exempt therefrom and the basis for the alleged esempdan. Any violation of
Section 70315 by any appliemm for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
D L as owner of the property, or my employers with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or thmugh his
own employees, provided that such improvements are not intended oroffered for sale. If,
however, the building or improvement is sold within one year of completims the owner -
builder will have the burden or proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the properly, am exclusively contracting with licensed contractors to
conswet the project (Sec 7044, Business and Professions Code:) The Contractors L.i-
ccnse Law does not apply to an owner of property who builds or improves thereon, and
.be contracts for such projects with a cor"clor(s) licensed pursuant to the Contractors
Licenx Law.
❑ I am exempt under Sec , B & P C for this reason
Owner LADate
WORKERS COMPENSATION DECRATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ f have and will maintain a Certificate of Consent to self-ias m for Worters Compen-
sation, as provided for by Section 3700 of the Labor Code. for the performance of the
wort for which this permit is issued.
have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued.
My Workers ComPe{
OF EXEMPTION FROM WO CERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant -
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction leading agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C-)
Leodces Name
Lenders Address
f certify that I have read this application and state that the above information is
correct- 1 agree to comply with all city and county ordinances and state laws relating to
Wilding construction, and hereby authorim representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities., judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON -POINT
SO GULL ONS.
U - C�
Signature of ApplieanthContimmor Mte
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hi nrdous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑ Yes C�Io'
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Ycs of o
(650)622-0330
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
WINDOWS REPLACEMENT (SIZE FOR SIZE) FOR NEW VINYL
WINDOW — 8 WINDOWS RETROFIT 1 DOOR SLIDER
Sq. Ft. Floor Area
3 5 6 0 4 0 2 5 ABW Number
Issued by:
Re -roofs
Type of Roof
Valuation
$
Occupancy Type
Required Inspections
Date f l�6
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
1 have read the haranlow materials requirements tmdcr Chapter6.95 or the Calirm-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a u7unt, that it is my responsibility to notify the occupant of the
mgvi w� mast be mey+�or to issuance of a Certificate of Occupancy.
Owner or au1ra_n7zd aecnt f Ef2u: —
Signature of Applicant Date
All roof coverings to be Class "B" or better