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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
.7777777
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BUILDING ADDRESS:
PERMIT NO.
OWN A
-'9"@0qP.2 0 0 % CONTROL NO.
ARCHITECTIFNGINEER:
BUILDING PERMIT INFO
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j LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job Description
1 hereby affirm that I am licensed under provisions of (commencing
with Section 70W) of Division 3 of the Business and Professions Code, andmylicense is
in full force and effect 3
- Licences Cla�s5ssLic. N
O�TNDWATER TREATMENT SYSTEM —PAD EQUIPMENT,
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] Date K Contractor
j ARCHITECTS DECLARATION
ENCLOSURE
I understand my plans shall be used as public records
Licensed Professional
j OWNER -BUILDER DECLARATION
I 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 construm 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 Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) 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
CCU anC
P y T,7 pe
Section 70315 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,
31609029.01
Required Inspections
will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors 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 employees, 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.).
❑ 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-
cense Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under See , B & P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 hive 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 Workcfs 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 Compeenns�
No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
,
(This section need not be completed if the permit is for one hundred dollars (EI00)
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 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
I hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
-
Lender's Address
I certify that 1 have read this application and state that the above information is
'
correct. 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorim representatives of this city to toter 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 Ci ty
S4�21
ApplicwVConlractor Date
HAZARDOUS MATERIALS DISCLOSURE
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 Safely
Code. Section
es 2ss32(a)? �Ne
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
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 o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor•
nia Health & Safely Code, Sections 2,5505.2,5533 and 25534.1 understand that if the building
does not currently h ve a enam, that it is my responsibility to notify the occupant of the
require nos ich sl mot riono )ssu ceof a Certificate of Occu ey.
Signature of Applicant Date
,l► v--
All roof coverings to be Class "B" or better
Owner
or authorized agent Date