09050113CY OF CUPERTINO
BUILDING DIVISION PERAUT
BUILDING ADDRESS:
PERMIT NO.
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OWNER'S NAME:
PERMIT ISSUE DATE
CONTROL NO.
ARCHrrECTIENGINEF.R: I BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
1 botchy affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in rull force and effect
License Class Lie.4
Date Contractor
ARCHr=S DECLARATION
I understand my plans shall be used as public records
Licansed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors 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
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(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
Section 70315 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500),
❑ L as owner of the property, or my employees with wage 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 Contractor's 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 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
,n 1, as owner of the property, am exclusively contracting with licensed camtractors 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
Lkeose Law.
❑ I am exempt under/8a,. B & P C for this mason
.Y
Owner '�
DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Workers Compcn-
satfon, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is Issued_
❑ 1 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 am:
Carrier. Policy No -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be compieted if the permit is for one hundred dollars (S 100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner 4as p bcc� Wafubject to the Workers' Compensation
Laws of Califorrim Date b /' 'L 0 ,
Applicant
NOTICE TO APPLICANT: If, after making this CeWricatc of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pcermii shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hemhy affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, CIv. C-)
Lenders Name
Lenders Address
I 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
building construction. and hereby authorise representatives of this city to enter upon am
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
Ifabilities,judgmems, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCEREGULATI7. OI ` Q
Signature of ApplicanUConuactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the appBnnt or future building ocupant store or handle hrrardous material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)7 �
❑Yes yJNo
Will the applicant or future building occupant use equipment or devices which
emit hazardous; air contaminant. as defined by the Bay Area Air Quality Management
District?
C] Yes 01Nu
1 have mad the ha7ardars materials requirements under Chapterti.95 of the Califor-
nia Health & Safety Codc, Sections 25503.25533 and 25534.1 understand that if the building
does not currently have a tenant that it is my responsibility to notify the occupant of the
anent b Date
Job Description
REVISION, REVISE TRUSS CALCULATION;ORIG #08070182
Sq. Ft. Floor Area
37536028.00
Required Inspections
Issued by:
Re -roofs
Type of Roof
Valuation
Occupancy Type
Date / 2
n
All roofs shall be inspected prior to any roofing material being instalred,
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class" ' or better