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CITY OF CUPERTINO�
BUILDING DIVISION PERMIT
BGILtiI> TIAENHART LN
J.A. CHAVEZ CONSTRUCTION
PERMrr No.
08010127
OWNER'S NAME'
PERMIT ISSUE DATE
:
SANITARY NO. CONTROL NO.
(408) 247-3006
ARCHrIECT/ENGINEER
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job Description
P
1 hereby affirm that I am licensed under provisions of (commencing
with Section 7000) ofDMsion 3 of the Business and Profiessions Codc, and my license is
REVISION, DRIVWY, WLKWY MTRL @FRNT EXT, DLT
in full force and elect -.
uanse Lie.M
WLKWY@SIDE &REAR, DLT#2 BDRM ON 1ST
T
Dale wacHTl'ECTSDEtor _Io C+
PLR,DLTFIREPLACE—ORIGINAL #7060039—NO NEW PERMIT.
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following mason (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 We a signed statement
is licensed to the of the Contractor's License Law 9
Sq. Ft. Floor Area
Valuation
that he pursuant provisions (Chapter
O
(commencing with Section 7000) of Division 3 of the Business and Professions Cadc) or
that he is exempt therefrom and the basis for cite alleged exemption. Any vlolauoa of
375150465 Number
Occupancy
P Y Type
Section 7031.5 by anyapplicant fora permit subjects Litt applicant to a civil penalty of
not mere than rive hundred dollar's (M).
❑ L as owner of the property, or my employers with wags as Lhrtir sole compensation,
Required Inspections
will do the work and the structum Is not intended or offered for sale (Sec, 7044, Business
and Professions Code: The Contractors Ljcm= Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employers, 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
sale.).
❑ L as owner of the Property, am exclusively contracting with licensed eontracrors to
construct the project (Sec 7044, Business and Professions Code:) The Contractor's U-
cense Law dos not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractar(s) licensed pursuant to the Contractor's
License Law.
.
❑ 1 am exempt under Sec , B & P C for Nis reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
-
I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
salon, 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 Worker's 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
'
COMPENSATON 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 1 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 Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shallbe damed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a con=ction lending agency for the performance of
the work for which it
that I have/ this application and stale that the above information Is
correct 1 agree to comply 'th Al city and county ordinances and stale laws relating to
building construction, and hereby authorise 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
liabilities, Judgments, cam and expenses which may in any way accrue against said Cry
in consequence of the granting of this permit -
APPLICANT UNDERSTANDS AND WI COMPLY WITH ALL NON -POINT
Issued by: Date
SOU EGULA'
Type of Roof
: ` 5 O
rg Appl' t/Con for Date
HAZARDOUS MATERIALS D oSURE
Will ppliant ix futuro building occupant m or handle haardous material
ci et by Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)? q�
Yes
❑ �
All roofs shall be inspected prior to any roofing material being installed.
t
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 d'JNu
I have read the h— ous materials requirements under Chapter6.95 of the.Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if to building
dos not currently have 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 "B" or better
O Date '
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