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CITY OF CUPERTINO �sTa,�-��
PERNUT
BUILDING DIVISION
r3U1LL�fV:G2/r
PEXMIT NO.
NSORWICH AVE
STONE CITY CORP.
08040040
SANITARY NO. CONTROL NO.
(510) 219-3632
ARC HTIECr/ETVGTNEFA:
BUILDING PEP MIT INFO
_
BLDG ELECT P{.UMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm the I am licensed under provisions of Chapter 9 (commencing
with Section7000)ofDivision3oftheBusinevandPro(casioosCode.anndmyucenmis
REVSN OF PRTL FNDTN PLN DETAIL& CHG DIRTN OF FLR
in Lic(ull fonce .eenseCClass�effeCL Lie.rT
JOINT ORIG #08030002
Date Contractor
ARCHITECT'S DECLARATION
1 urdcrstand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
-
1 hereby affirm that i am exempt from the Contranoh License Law for the
following reason- (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to eonsu ict, slier, improve, demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
he is licensed to dm of the Contractor's License Law (Chapter 9
Sq Ft. Floor Area
Valuation
the pursuant provisions
.
rr 0
(commencing with Section 7000) of Division 3 or the Business and Professions Code) or
Y
drat he is exempt therefrom and the basis for the alleged exanpdon. Any violation of
�p Number
31629087
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SS00).
: t1
❑ 1, as owner of the property, or my employees with wages as their sole compensation.
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7D44, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
Property who builds or improves thereon, and who does such wort himself or through his
own employees, provided that such improvements are not interacted or offered for sale. if,
however, the building or improvement is sold within one year or completion, the owner.
builder will have the burden of proving that he did not build or improve for purpose of
saIC4
,P/L as owner of the property, am exclusively contracting with Bcenmd contractors to
construct the project (Sec. 7044, Business and Profession% Code:) The Contractor's Li -
cease Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contracwKs) licensed pursuant to the Contractor's
License Law.
❑ I am
T70N
I hereby affirm er penalty of perjury cf oBowing declarations
❑ I have and will maintain a CertfGate of Consent to self -Insure for Worker's Compcn-
sation, u provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued
❑ I 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 Worker's Compensation Insurance carrier and Policy number ate:
Carrier; Polity No.:
CERTIRCATE OF FXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secdon need not be completed lithe permit is for one hundred dollars i 10(3)
or less.)
1 certify that in the performance of the work for which this permit is issued. I slug not
employ arty person in a annerso a to b me subject to the Works Compe sati
Laws of California.
Lion, yo should
become subject to the Wo s Compcntido cans or the Labor Code, you must
Labe
forthwith comply with such provision% or this permit shall be deemed revoked
I
CONSTRUCTION LENDING AGENCY
� I hereby aRirm that these is ■ conswction lending agency for the performance of
the work for which this permit is issued (Sec 3097. Civ. C.)
'
Lendees Name
LAmdees Address
1 I testify that I have read this application and state that the above information is
-
coreeL I agme to comply with all City and county ordinances and state laws telating to
building concoction, and hereby amhorira representatives of this city to enter upon the
above-mandoned property for inspection purposes.
(We) agree to Save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgrnrms, costs and expenses which may in my way acrnc against said City
' in consequence of the granting of this permit.--
' APPLICANT
DISCLOSURE
Wits the applicant or Future building oct9fantstorc or handle hazardous material
_
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Conk:, Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yu ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Ara Air Quality Management
all new materials for inspection.
District?
❑Yes [:I No
I have read the hLzarlau materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Codc, Sections 25505, Z5533 and 2.5534.1 dmdcrsund the if the building
sire
does not have a Tenant. that it is
Da