08100181 CITY OF CUPERTINO PERNIITW111 .
z s Fr
BUILDING DIVISION a Y
BUILDING ADDRESS: PERMIT NO.
10201
OWNER'S NAME: PERMIT ISSUE DATE
PHO CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
a o 0 LICENSED CONTRACTOR'S DECLARATION
• U I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in Full force andeffecL $S NO COMML TI i INTER WK:SHTRK 2 ALCVS,ADD DOORS IN 2
3M� License Class 1_1 DateCCoon f Contractor :e-o eat- LOC, DEMO DECRTVSHTRCK, PAINT,CARPET&TILE
ARCHITECT'S DECLARATION
I understand my plant shall be used at public retards
�qU
o Licensed Professional
0 OWNER-BUILDER DECLARATION
F 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
p 0 following mason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a pcmtit to comslrut,sits,'improve,demolish,or repair any structure
prior to is issuance,also requires the applicant for such permit to file a signed statement
_ that he Is Ilceascd pursuant to the provisions of de Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
t— (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that he is exempt timefrom and the basis for the alleged exemption Any violation of
Section 70315 by any applicant for a permit subjem the applicant to a civil penalty of APN Number Occupancy e
ndt more than five hundred dollars(5500). P Y •]P
❑L as owner of the property,or my employees with wages as their sole compensation, 3 6 9 410 0 5 .M P
win do the wort,and the structure is runt intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employers,provided that such improvements are not intended car offered for sale IL
however,the building car 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
❑L as owner of the property,am exclusively contracting with licensed contraetots to
corumuct the project(Sec.7044,Business and Professions Code:)The Coouxtors Li-
cense Law does not apply to an owner of property who builds or Improves thereon,and
who contras for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law,
❑1 am exempt under Sec ,B&P C for this reason
Owns Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declaration
❑1 have and will maintain a Certificate of consent to self-insure for Worker's Compen-
sadon,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which ads permit is issued
❑1 have and will maintain Wonters Compensation Insuranca,as required by Section
3700 of the Labor Code,for the performance of the work for which dus permit is Issued
My Work
Q,.�3 ComponWion Insurance carrierearP� sty n her are:
Cartier./1,`�tn°IMCG LOMA`lt'►'� Policy No.:
CERTIFICATE OF EiEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not be completed If the permit is for Oise hundred dollars(S 100)
or leer)
I certify drat in the performance of the wort for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workcr's'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenifncale of Exemption,you should
become subject to the Wmknds Compensation provisions of the Labor Code,you must
0 z forthwith comply with such provisions or this permit shall be deemed revoked
a CONSTRUCTION LENDING AGENCY
[--r 1 hereby off.that there is•construOrm lending agency for the performance of
qG the work for which this permit is issued(See.3097,Civ.Ca
W Q Leadees Namc
z Lenders Address
U O 1 cardfy that I have read this application and sum that the above Womwtion is
ITr correct 1 agree to comply with all city and county ordinances and stale laws relating to
V building conswctiom and hereby authorize 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
r..r liabilities,judgments,toss and expenses which may in any way accrue against said City
U z in consequence of the granting of this permit
114 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE TiONS. _
Z M Re-roofs _
SIgnr of AppIicanVC9RfiybWrDale
US MATERIALS DISCLOSURE Type of Roof
Will the apply or future building occupant store or handle hazardous material
as defined by de Cupertino Municipal Code,Cbapw 9.12 and the Health and Safety
Code,Section 25532(a)? � All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants u ned by the Bay Area Au Quality Management all new materials for inspection.
DisuicO
❑Yes o
1 have read the hazardous materials rcquiremens under Chsptcr 6.95 of the Cali for-
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if dtc building
does not curtendy have a tenant,that it is my responsibility to notify the occupant of the
requirements mtul met pri rto issu of a Crxti ate of Signature of Applicant Date
r
- � All roof coverings to be Class'n"or better
O or author 7:cd agent Dam