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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
21757
GE
OWNER'S NAME:
PERMIT ISSUE DATE
A CONTROL NO.
408)496-0159
ARCHnECi/ENGINEER:
BUILDING PEILMrr INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(L)) of Divsion 3 of the Business and Professions Code. and my license is
in full force and effecL
REVISION FIRE REQUIREMENTS, STRUCTURAL, ORIG
License Class Lk. 1
Date Contra=
07020115 NO NEW PERMIT. SEE PERMIT #08090092 FOR
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
FEES.
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a permit to construct, alter, improve, dcmollsh, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
so
APN Number
Occupancy Type
Section 70313 by any applicant for x permit subjects Use applicant to a Civil penally of
net more than five hundred dollars (5500).
35717056.57
❑ I. as owner of tie property, or my employees with wages as thew sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors Licarm Law daze 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 oroffered for sale. 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 property, am exclusively contracting with licensed contractors to
construct the project (Sec 7044. Business and Professions Code:) The Contractors Li-
cense Law doe{ not apply to an owner of property who builds or improves thereon, and ,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec , B k P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations
❑ I have and will maintain a Certificate of Consent to self -insure far Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued
0 I have and will maintain Workers 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 Compensation Insurance carrier and Policy number are:
Canicr:Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
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' Compersaton
Laws of California Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of Ue Labor Code, you must
forthwith comply with such provisions or this permit shall be dearned revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performancc of
the work for which this permit Is issued (Sec, 3097, Civ. C.)
'
Lenders Name
,
Lenders Address
1 certify that I have read this application and state that the above information is
correcL I agree to comply with all city and county ordinances and state laws relating to
building construction. and hereby authorize representatives of this city to enter upon to
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments. costs and expenses which may in any way acrnhe against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signature of ApplicanUContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes 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 Area Air Quality Management
all new materials for inspection.
District?
❑Yes [3 No
1 have read the hazardous materiels requirements under Chapter6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not currently haw a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy.
Signature Of Applicant Date
All roof coverings to be Class'." or better
rl-- .ham i, Aoornt Date