07100171BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PERMIT NO.
OWNER'S
ARCHn"EC IENGTNEER:
i Zp LICENSED CONTRACTOR'S DECLARATION
i hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U with Section 70W) of -Division 3 of the Business and Professions Code. vand my liters= is
a in full force and effec -Z % O
i Licen as f.f % 8
n Date Contractor
ARCHITECT'S DECLAIIATION
1 understand my plans shall be used as public records
=U
F- Licensed Professional
a OWNER -BUILDER DECLARATION
� f I hereby atTirm that 1 am exempt from tltc Contractor's License Law for the
OC following rcason. (Section 7031.5. Business and Professions Code: Any city or county
li 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
a that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
'- es
$ (commencing with Section 70D0) of Division 3 of the Business and Professions Cote) or
i:.• 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 ($500).
❑ 1, as owner of the property, or my employees with wages as thew sole compensation,
will do the work and the structure is not intended or offered for sale (Sec.7044, Business
and Professions Cod-- The Contracor'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 improvwenLs are not intended w offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner-
hu0der 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
constm ict the project (Sec 7044. Business and Professions Code:) The Contractor's Li-
ccnse Law does not apply to an owner of property who builds or Improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec , B & P C for this reason
Owner am —
WORKER'S COMPENSATION DECLARATION
I hereby aCrrrm under penalty of perjury one of the following declarations:
[(I have and will maintain a CertlGcate of Consent to self-insum for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Cote, for the performance of the
work for which INS pcMit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37DD of the Labor Code, for the performance of the work for which This permit is issued
My Worker's 5Compensation Insurance carrier and Policy number am::
Carrier. I ATV-- CO-Vi F-7 G
Policy No.: 04 b CQ lJ r f ;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or Icm)
I certify that in the performance of the work for which this permit is issued. I shall not
employ anyperson in any manner so as to become subject to the Workers' Compensation
Laws ofCaliromia. Date
Apptidam
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should
become subject to the Worker's Compens ition provisions of the Labor Code, you most
I ,Z forthwith comply with such provisions or this permit shall be deemed revoked.
C
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a} construction lending agency for the performance of
> the work for which titia permit is issurA (Sec 3097, Civ. C.)
QLender's Name
Z Lender's Address '
C I certify that I have read this application and state that the above information is
r-o correct 1 agree to comply with all city and county ordinances and state laws relating to
j V building construction, and hereby authorim representatives of this city to enter upon the
W above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
rA liabilities, judgments, toss and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WiTH ALL NON -POINT
SOURCE REGULATIONS.
Signature of Applicant/Contraclor Dater
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuuue building oceupwu store or handle hazardous material
as damned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)? //''
❑Yes ZNI
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Manegemew
District?
❑ Yes L_TNu
I have read the ha7ardots materials requirements under Chapter &95 of the Califor-
nia Health & Safety Code. Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a icnant. that it is my responsibility to notify the occupant of the
requirement) vj i mu3LbeVg licipr to issuance of a Certificate of Occgpancy. ,
S&1'0�q
CONTROL NO.
BUILDING PERMrr INFO
ELECT PLUMB MECH
Job Description
T.I.; MINOR INTERIOR 2 NEW SINGLE USE;
OMS. PRINCIPAL BUILDERS, INC BSL PD
10/23/07
Sq. Ft. Floor Area
APN N
316200
Required Inspections
OG
Issued by:
Re -roofs
Type of Roof
on
Type
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 "B" or better
Date