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CITY OF CUPERTINOIN
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BUILDING DIVISION PE
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BUILDING ADDRESS:
PETER HERNAN
PERMIT NO. 04070074
:
PERMIT L%UE DATE
PHONE:
SANITARY OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(l0) of Division 3 of the Business and Professions Codc, and my license is
in fall force and effect
License Class Lic.0
ACCESS. BLDG. (1431') (ART STUDIO/SHOP
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to concoct, alter, improve, demullsh, 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
Va uatlon
(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
3 1MIR3e10 0
Occupancy Type
Section 7031.5 by arty 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 their sole compensation,
Required Inspections
will do the work, and the structure isnot intended oroffered for sale (Sec.7044,Business
and Professions Code: The Contractor's License Law does not apply to an owner of
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property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are nor intended oroffemd 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.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 70". Business and Professions Code:) The Contractors Li—
cense Law does not apply to an owner of property who builds or improves thereon, and.
-
who contracts
"l-foMowing declarations:
❑ 1 have and will maintain a Certificate of Consent to self -insure for Worltcrs Compen-
sation, as 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 performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars ($100)
carless)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any persb in any manner so as to become subject to the Workers Compensation
La s of Califorpla. -
Ilranl
GnCE TO APPI11CAPWIS. after making this Certificate of Exemption, you should
become subject to orkers 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 far which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address—��-
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
j Ilabilides, judgments, costs and expenses which may in any way accrue against said City
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in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SO U AT10NS.
Re -roofs
Type of Roof
27 00 04
ignat re Applicant/Contractor ate
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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 Safety
Code. Section 25532(a)?
All roofs shall be inspected to any roofing material being installed.
❑Yes arNo
prior
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 No
I have read the hazardous- materials requirements under Chapter 6.95 of the Califor-
nia Health & Safely Code, Sections 25505.25533 and 25534.1 understand that if dre building
does not c rrcnil have a tenant that it is my responsibility to notify the occupant of the
rcquirem s hic must be met prior to issuance of a Certificate of �Occup�an--c�y. ` ,
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Dare
Owner a on ed agent