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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT�'R�Q'
BUILDING ADDRESS:
PERMIT NO,
OWNE
PHON
CALA AVE.
s"K04Q- 2 0 0 7 CONTROL NO.
ARCHn=fENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'SDECLARATTON
Job Description
1 hereby 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
LiceneClasand errtxt d
License Class Lic. p
TEMPORARY PERMIT -WEST ENTRY VALLCO EXTERIOR-2ND
Date 49 Con"
DEC o �
ARCHIpELTS DECL.AR
RENEWAL GOOD FOR 30 DAYS -EXPIRES 05/04/07. ORIG
d understand my plans shall be used as public records
PERMIT # 0 7 0 2 0 0 2 8 — 1ST TEMP PERMIT # 0 7 0 3 0 017 .
Licensed Prufcssional
OWNER -BUILDER DECLARATION
I hereby aifirm that I am exempt frum the Contractor's 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, alsu requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that be is licensed pursuant to the provisions of the Conuaclor's License Law (Chapter 9
(commencing with Section 70DO) 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
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars ($W.
), as owner of the property, or my employees with wages as their sole compensation,
3 16 2 0 0 3 7 0
Required Inspections
will do the work, and the structure is not inlended 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 himadf or through his
owo employees, provided that such improvements are not inteoded or offered for sale. If,
however, the building or improvement is sold widen one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li -
cc= taw does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a eomnictor(s) licensed pursuant to the Contractor's
License Law.
Q lamexempt under Sec B & P C for this reason
Owner Date
WORKEtS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ 1 hsve and will maintain a Certificate of Consent to self -unsure for Worker's Compc t-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which Ihis 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 Co m enaad n IrLnuw a atria and Policy number arc:
�(
Carrier. Policy No.:
CERTMCAYE-UP EXElvIPTION FROMWORKERS'
COMPENSATION INSURANCE
(This section need not be completed lithe permit Is for one hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, I shall not
employ arty person in any manner so as to become subject to the Workcrs' Compensation
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 the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ, Q
Lenders Name
,
L,cndces Address
1 certify that I have read this application and state that the above information is
cored I agree to comply with all city and county ordinances and state laws rclaang to
building construction, and hereby authorim mprrxntatives 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 permiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date C�i L7 —ice
SOURCE REGULATIONS.
Re -roofs
Type of Roof
O
Signature of lie nt/Co De
HAZARDOUS MATMALS DISCLOSURE
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
cnuc, Section
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes �40
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 dcfnncd by the Bay Area Air Quality Management
all new materials for inspection.
Disrict7
13Yes lJ'
I have read the hazardous materials requirements under Chapter 6.95 of the Califor•
nia Health & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a lcnant, that It is my responsibility to notify the occupant of are
requirements which must be met prior to iManee of a Cc,t )Kale of aNpaney.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authtuizcd agent Date