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CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT�A�9k:F
BUILDING ADDRESS:
PERMIT NO.
Y495 PROSPECT RD
TBD — TO BE DETERMINED
08080114
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under previsions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Coda, and my license is
REPLC E NEW - S I DNG ON 2ND FLR , R E PLC NEW
in full force and effect
I.keatc Class - Lk. N
WNDWS , REPLC '
Date ARCHT ECrrS DECLARATION
DRYWL C E I LNG ON 1ST FLR
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby alTirm that 1 am exempt from the Contractor's License Law for ono
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requites a permit to consuvct, alter, improve. demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed to the the ConLrwWelLicens: Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions of
3 5 0 0
(commencing with Section 7000) of Division 3 of Ore Business and Professions Code) or
$
drat be is eaesnpt therefrom and the basis for the alleged exemption- Any violation of
Number
36615053
Occupancy Type
Section 7031.5 by try applicant for a permit subjects the applicant W a civil penalty of
not more mfive soo). an e htmdred dollars (s
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered forsale (Sec 7044. Busiotas
and Professions Code: The Contractor's License Law does not apply W an owner of
property who builds or improves thereon, and who does such work himself or through his
awn employees, provided that such improvements are not intended or offered for seek. If.
however, the building or improvement is sold within one year of completim 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 wad Professions Code:) The Cootrimors Lb
tense Law dos not apply W an owner of property who builds or improves thereon, and,
who conuacts for such projects wit) a eontractor(s) Ikaaxd pursuant to cite Contractors
License Law.
❑ 1 an exempt under
affirm under penalty of perjury one of the following declarations;
❑ 1 have and will maintain a Certificate of Consent W self -insure for Worker's Compen-
sation, 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 mainWn Worker's Compertudon Insurance, as required by Section
3700 of the Labor Code, for the perfonnanco of the work for which Otis permit is Issued
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed If the permit is for one hundred dollars (S 100)
or ksa)
I certify that in the performance o thS w rk for which this permit 4 issued. I shall not
employ any person in any mariner ecoma subject W the Worked Compensation
Laws of Califomda Date
ApplicauI
NOTICE TO APPUCANT: If, eking this Certificate of Exemption, you should
become subject W the Workers Compeandon 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 consuvction lending agency for the pertormancc of
the work for which this permit is issued (Sec 3097, Civ. C.)
Lender's Name
,
Lender's Address
I certify dart I have read this application and state that the above Information Is.
con=L 1 agree W comply with all city and county ordinances and state laws relating to
building constmction, and hereby authorize reprtsentatfves of this city W enter upon the
above -mentioned property for inspection purposes.
(We) agree W save, indemnify and keep harmless the City of Cupertino against
Iiabilitimjadgmenu.costs and expenses which may In any way accrue against said City
9�_�
in of the gran
APPLICANT UNDER sing S_D WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATTO
Re -
Type of Roof / C
t
Signature ofAppfi r Dart
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Codc. Chapter 9.12, and the Health and Safely
Coda, section 25532(a)+
❑ Yes No
All roofs shall be inspected prior to any roofing material being installed.
0
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building omnpam use equipment or devices wheel,
emit hazardous orcu'us ninany/1G, as defined by the Bay Arcs Air Quality Management
all new materials for inspection.
District?
❑Yee ❑No
1 have read the ti ;zardo s materials requirements under Ciupter6.95 of the Califor-
nia Health & Sal6ty Cqdc. Sonless 25505, 25533 and 25534.1 u der nand that if the building
does net curtendY ha tenth, that u o my responsibility W notify the occupant of the
requirertrents which 'or to issuanx of a Certificate o Oc
2
Signature of Applicant Date
f
All roof coverings to be Classor better
Owner or sum
Datc