08050168BUILDING DIVISION PERMIT
OVE CT
OWNER'S NAME:
:
ARCHITECT/ENGINEER:
O C LICENSED CONTRACTOR'S DECLARATION
v f: 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
z with Section 70(X)) of Diviaon 3 of the Business and Professions Code, and my license is
< d in full force and effect.
7 N
i � ? License Class Lic, p
F W Date Contractor
• ARCHITECT'S DECLARATION
ae I understand my plans shall be used as public records
ryU
U.
rn Licensed Professional
• y to OWNER -BUILDER DECLARATION
f 1 hereby affirm that I am exempt from the Contractor's License Law for the
❑ Ofollowing reason. (Section 7031.5, Business and Professions Code: Any city or county
0
% m which requires a permit to construct. alter• improve, demolish, or repair any structure
•" rn prior to its issuance• also requires the applicant for such permit to file a signed statement
Za
I-� that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 70D0) 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 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ 1, as owner of the property, or my employees with wages 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 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's U.
cerise Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a eontraelor(s) licensed pursuant to the Contractor's
License Law. '
❑ 1 am exempt under,Sep. _ . B & P Cppfor this mason
Owner il`�•`�-� Date
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-insum 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 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 Worker's Compensation Insurance artier and Polity number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPFNSATION INSURANCE
t
(rhis section need not be completed if the permit is for one hundred dollars (EIOD)
or less.)
1 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 bytttojcct to the Workcrs' Compensation
Laws of California. D e
Applicant
NOTICE TO AI L) y : 1f. after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Codc, you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z CA CONSTRUCTION LENDING AGENCY
,.
[� �•+ I hereby affirm that them is a construction lending agency for the performance of
IYi J the work for which this permit is issued (Sec. 3097, Civ. C.)
W Q Lenders Name
p+ Lender's Address
U 0 1 certify that 1 have mad this application and state that the above information is
(Jr t cortecL 1 agree to comply with all city and county ordinances and state laws relating to
0 building construction, and hereby authorise representatives of this city to enter upon the
W above -mentioned property for inspection purposes
CL (We) agree to save, indemnify and keep harmless the City of Cupertino against
HlA liabilities, judgments, costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit
�'--' APPLICA DERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE ONS- " ,t /� 91
SSr nature of Applicam/Contractor Date
Applicam/Contractor�D/ate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardaus material
as defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Section 25532(a)?
❑Yes :No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminanis defined by the Bay Area Air Quality Management
District?
❑ Yes ❑ No
1 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 tenon that it is my responsibility to notify c cup��§nnnt of the
requirements which mu nor to issuanc cy
Owner or authorifEd agent r Date
TBD — TO BE DETERMINED
PERM I NU.
08050168
PERMIT ISSUE DATE
08/05/2008
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
CONVERT (E) CARPORT TO ENCLOSED GARAGE 230 SQ FT.
Sq. Ft. Floor Area
37541032 �(34Number
Issued by:
Re -roofs
Type of Roof
$6000
Required Inspections
Type
Date d-- J ,
All roofs shall be inspected prior to any roofing material being installed.
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