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BUILDING DIVISION PERMIT
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BUILT1j46ApQR
PERMIT NO.
MERRIMAN RD
D & D CONSTRUCTION
08050001
SANITARY NO. CONTROL NO.
(408)666-5298
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BL.DG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70DO) of Division 3 of the Business arid Profession; Codc, and my license is
DEMO HOUSE AND DETACHED GARAGE. WOOD SHED TO BE
in full fora and effecr-
License Class _ Lie. N
DEMOLISHED.
Datc Contractor
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am citempt from the Conuaators License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
to the of the Conuacim's License Law ((]taper 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant provisions
12 0 0 0
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
34216074 Number
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).
.
0 L as ovmel of the property, or my employees with wages w their sole compensation,
Required Inspections
will do the worn. 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 through his
own employees, provided that such improvements are not intended or offered for We. if,
.
however, the building or improvement is sold within one year of completion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
(1. as owner of the propeny, am exclusively contracting with licensed eantractors to
.
construct the project (See. 7044, Business and Proftdons Code;) The Contactors LS-
cum law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
L.iccnse law.
0 I am exempt and S , B& P C for this reason
Owner Date 1 / O
WOR 1 PENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declanations:
0 I have and will maintain a Certificate of Consent to self -insure for workeesConpen-
sation, n 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 Compensialon Insurance, as required by Section
3700 of the labor Code, for the performance of the work for which this permit is issued
'
My Workers Comperisadon Insurance curler and Polity number are:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (SI00)
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 gs to become subj- o the workers' Compensation
Laws of Caldomi•'Le_
Appliram
NOTICE TO A
provisions of the Labor Coda, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a commcdon Lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C-)
'
Lenders NI me
,
Lender's Address
j I artify that I have read this application and state that the above information is
' correct- I agree to comply with all City and county ordinances and state laws relating to
ibuilding construction. and hereby authorix represenuti rs 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
j liabilities, judgments, toss and expenses which may In any way acauc against said City
in consequence of the grandog of this pnnmll.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued Date
SOURCE REGULATIO�
Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oavpant store or handle huArdous material
as defined by Um Cupertino Municipal Code. Chapter 9.I2, and the Health and Safety
Code, Section 25532(a)?
El Yes
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
Will the applicant or future building occupant use equipment or devices which
erall hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
D Yet �No
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505. 25533 and 25534_ I understand that if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of
requirementswh Met prior toissuance ofaCertificate ofOccupancy .
Signature of Applicant Date
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All roof coverings to be Class'W!t' or better
Owner or authorized ag Da,c