08060120CITY OF CUPERTINO
DIVISION PERMITPER
BUILDING
BUILTI6041 ss: TANTAU AVE
NN
NOVO CONSTRUCTION
IT NO.
08160120
OWNER'S NAME:
PERMIT LgUE DATE
.
1042 HAMILTON CT
07/03/2008
PHONE.
SANITARY NO. CONTROL NO.
(650)701-1500
ARCHITECTIENGINEER:
BURRING PERMIT iNFO
BLDG ELECT PLUMB L MECI-1
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
C OMM ' L T I r BU I LD OUT EXISTING BLDG (5171 S Q) ; NO
;nrullroraand efrect� Lie x ��ilpL2
in full f sass
RE —ROOF OR STRUCTURL. PARKING WORKED OUT PRIOR TO
Date Contramr NOVO Co
ARCHTrECrS DECLARATION
FINAL.
1 understand my plans shall be used as public records
Licensed Pmfesdonal
OWNER -BUILDER DECLARATION
i hereby affirm that 1 am ccempt from the Contractor's License Law for Use
following reason. (Section 70315, Business and Ptoressiom 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 porauant to the provisions of the Contractors License Law (Chapter 9
Sq . Ft. Floor Area Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 3 0 0 0 0 0
that he is exmpt therefrom and the basis for the alleged exemption. Any violation of
Number
316 0 5 0 5 6 um
Occupancy
Type
Section 7031-5 by any applicant for a permit subjects the appliam to a civil penalty or
not mom soo>. than five hundred dollars (s
.
❑ L, its owner of the property, or my employees with wages as their sole compensation,
Required Inspections
willdo the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions coda: The Contractors License Law does not apply to an Owner of
property who bui ds or improves thereon. and who does such wort himself or through hat
own employees, provided that such improvements am 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 Contractors Li-
cense Law does not apply to an owner of progeny who builds or improves thereon, and .
who contracts for such projects with a comae or(s) liamsed pursuant to the Contractors
Llcense Law.
❑ 1 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 haw and will maintain a certificate of Consent to self-insuR for Workers Compme
salon, u provided for by Section 3700 of the Labor Code, fro the performance of the
work for which this permit is issued
❑ 1 have and will maintain Worker's Compensation Imsurance, as required by Section
3700 of the Labor Code, for the performance of thre work for which this permit is issued
My Workes Compensation
91 — 09
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
-
(ihis section need rot be completed lithe permit is for one hundred dollars (SI00)
or less.)
I certifv that in the perfommana: 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' Comperu ation
Laws of California. Dw
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 affum that tiumre in a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ, C.)
Lenders Name
Lenders Address
1 certify that I have read this application and state that the above information Is
correct I agree to comply with all city and county onftnances and state laws relating to
building construction, and hereby auLhorize representatives or this city to enter upon the
above -mentioned property for inspection purposes
(We) Agra to save, indemnify and keep harmless the City of Cupertino against
liabi ' gmcota, cods and expenses which may in any way accrue against said City
;n of the granting of this pmrrtit.
A ICA U F3 ANDS AND WILL C PLY W N N- INT
Issued by: Date
URGE
/7
Type of Roof
Signature Appli an Date'
us MAT ER1ALs I sinus
11 tin applicant or forum building - ore or handle hazardous material
u deft by the Cupertino Murtidpal Cgdc. Ch 9.1Z and the Health and Safety
Code. Section 25532(a)? /
❑ Yes 0,1(O
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 u drain the Bay Area Au Quality Management
all ew ateri s for inspection.
D strict?
❑ Yes o
1 have the haardous materials requirements under Chapter &95 of the Califor-
N & S ty Code, Sections 25305. 25533 and 25534.1 understand that if the building
/
1
(� �os
y haw a tenant, that It is my risibility to notify the occupant of the
Ir
qu; c a Certificate of cw
S06 igma
r coverings to be Class " " or better
g
Da1C
Own r or anthornrd agent