080300020
zc
W�
i3+
UC
V.
o t
r tj
U
r-r U
U2
CITY OF CUPERTINO
;� P.
BUILDING DIVISION PE T
sW A.
BU'T6'Z,y�o3RTORWI CH AVE
TBD — TO BE DETERMINED
PET: 8 MIT NO.
:
SANITARY NO. CONTROL NO.
ARCHITEC.TIENGINEER:
ADD 364SQ DEN & LIVING,4TH
BUILDING PERMIT INFO
ELECT PLUM MECH
0 0 0 0
LICENSED CONTRACTOWS DECLARATION
' ^ "' �• "--" -,—,eb-Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Seedon 7000) of Division 3 of the Business and Professions Code. and my license is
in full form and effem
License Class L ic.
Date Contractor
ARCHr(BCrS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I herchy affirm that i am exempt from the Contractor's License Law for the
following reason. (Section 7131.5, Business and Profession Coder: Any city or county
which requires a permit to conMtcL alter. improve, demolish, or repair any structure
Sq. Ft. Floor Area
Valuation
prior to its issuance, also requires the applicant for such permit to file a signed statement
Law 9
that he is licensed pursuant to the provisions of the Conimtor's License (Cbapter
(commencing with Section 70M) of Division 3 of the Business and Profession& Code) or
that he is exempt therefrom and the bass for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars (S500).
❑ L, as owner of the property, or my employees With wages as their sole eormptrsaden,
Required Inspections
4 p
will do the work, and the structure Is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contrxwes License Law does not apply to an owner of
property who builds or improves tbereon, and W ho does such worit himself orthrough his
won 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-
bulldy will have the burdem of proving that he did not build or improve for purpose of
, as owner of the property, am exclusively contracting with licensed contractors to
eons vuct the project (Sec 7044, Business and Professions Code:) The Contractor's L)-
.
cease Law does not apply to an owner of property who builds or impmoves thereon, and.
who contracts for such projects with a contractor(s) ricmxd pursuant to the Contractor's
License Law.
❑ I am exernp
hereby trre under peaatty o of the (ollawing declarations
❑ 1 have and will maintain a Certifiale of Consent to self-insum for Worker's Compcn-
sadon, u 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 performancz of the work for which this permit is issued.
My Worker's Compensation insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
0-his section teed not be completed if the permit is forone hundred dollars (S I00)
or lets)
1 certify that in the performance of the work for which this permit is issued. 1 shall not
employ airy
Y
NOTICE 17 P , atter ma g orris niCrate of Exemption, you should
become subjcc to Worker's Campcnsuitfon p 'cans of the Labor Code, you mew
forthwith rem 'th such provisions or this _ it rha11 be tamed rewked
i
' CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a Construction lending agency for the performance of
the work for which this permit is issued (Six- 3097, Civ. C-)
Lender's Name
Lender's Address
1 certify that i have mad this application and state that the above information is
co=cL I &&me to comply with all city and county ordinances and state laws relating to
building constriction, and hereby authorize 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
s
I liabilities, judgments, toss and expenses which may in any way acme against said City
in consequence of the granting of this permit
APPLICANT U ERSTANDS AND WILL OMPLY WITH ALL NON -POINT
Issued b Date tt
y t&W
REG
MATERIALS DI LOSURE
Will the ap t or future building occupant stoic or handle haardous material
as defined by the Cupertino Municipal Code, Chapter 9At and the Health and Safety
Code, Section25532(a)?
❑ Yee �b
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 Ares Air Quality Management
all new materials for inspection.
District?
❑ Yes o
1 have mad the hiumrdous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Ccdc, Sections 25505, 25533 and 25534.1 understand that if the building
does not cunendy have a ter+ant. that it is my responsibility m notiry the occupant nr the
r_quiremcroswhichmtwbeMetpriortoissumccoraCertificateofOccupaw.
Signature of Applicant Date
All roof coverings to be Class'` or better
Date
Owner oraulhortyzdagent