06110034CITY OF CUPERTINO
BUILDING DIVISION PER1V'�1llJ�� e
BUILDING ADDRESS:
ALLBRAND WINDOWS
PERMIT NO. .
06110034
:
SANITARY NO. CONTROL NO.
(650) 622-0330
ARCHITECTIENGINEER:
BUILDING PERMIT 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 7000) of Division 3 of the Business and Pro(csSions Codc, and my license is
in full force and effect— ,• S
REPLACING WINDOWS: 3 RETROFIT, 2 PD NF/ W/ STUC
License las Lic. ar
Dais Contractor re
PATCH. 3 WINDOWS WITH REFRAME, NF W STUCCO PATC
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed 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
Sq. Ft, Floor Area Valuation
(commencing with Section 70DO) of Division 3 of the Business and Professions Code) or
$ 8 3 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
APN Number Occupancy Type
not more than five hundred dollars ($500).
C] 1, as owner of the property, or my employees with wages as thew sole compensation,
will do the worst, and the structure is not intended oroRered forsalc (Sec.7044, Business
Required Inspections '
and Professions Code: The Contractors License Law does not apply to an owner of
9
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 property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractors U.
tense 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 Contractors
License Law.
C] I am exempt under Sec , B & P C for this reason
Owner Date
WORKER'S COMPENSATION 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 Compen-
sation, as 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 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
FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if die permit is (o-rone 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' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performanLc of
the work for which this permit Is issued (See. 3097, Civ. C.)
L.endcrs Name
'
Lenders Address
7
I certify that 1 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
building construction, and hereby authorim representatives 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
n liabilities, judgments. costs and expenses which may In any way accrue against said City
7 in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date —
Re -roofs
Signature of Applicant/Contracior . ate
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof .
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, Section25532(a)7
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 Duality Management
all new materials for inspection.
District?
❑ Yes o
I have real the hazardous materials requirements under Chapicr G95 of ncc Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not
I
7—
All roof coverings to be Class "B" or better
Owner or authorized agent ate