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ARCHITEcTIE.NGINEER:
LICENSED CONTRACTOR'S DECLARATION
I 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
in full force and eft
License (lass Lfc. N
Date Co!_
ARCH DEC 7TON
I understand my plans &hall be used sat public records
Licensed Professional
OWNER
WNE "BUILDER DECLARATION
1 hereby of rim that 1 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 conv=4 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 pursuant to the provisions of the Contractor's License Law (Chapter 9
(commenting with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and due basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to ■ civil penalty of
not most than five hundred dollars (S500).
❑ L as owner of the pmp=Ty, or my employees with wages as their sole compensation,
will do the work. and the structure is not intended or ofreed for sale (Sec. 7044, Business
and Professions Code. The Contractors License Law does oat apply to an owner of
property who builds or improves thereon, and who does such work himself or through his -
own employees, provided that such improvements am not intended or offered for sale If,
however, the building or improvement Is sold within ear 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 7044, 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 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
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby &tram under penalty of perjury one of Use following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
salion, u provided for by Section 3700 of the Labor Code, for the perfonnamx of the
work for which this permit is issued
1 have and will maintain Worker's Compensation Inswvcc, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Worker's omppersattion Insurance carrier and Policy number arc:
] �!-
Card= IC/ Polity No.: Ka
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit Is for one hundred dollars (2100)
or Tess.)
1 certify that In the performance 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' Comperaadom
Laws of California Data
App6t:am
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this pcvnil shad] be deemed rooked.
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 (Sec. 3097, Civ, C)
Lender's Name
Lenders Address
f certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and cowry 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
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue againUsaid City
in consequence of the granting of this permit.
APPLICANT UNDERS:rANIPS AND WILL COMPLY WITH ALL NON -POINT
SOUgk'!I
Ll HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as damned by the Cupertino Municipal Code, Cbaptcr 9.12. and the Health and Safely
Code, Section 25532(a)7 �
❑ Yu (a'No
Will the applicant or future building occupant usecquipment or devices which
emit hazmdots air contaminants u damned by the Bay Area Air Quality Management
Disuit:0
❑ Yes
1 have toad the haardous materials requirements under Chapter 6.95 of the Califor-
nia Health k Safely Code, Sections 25505. 25533 and 25534.1 understand thatif the building
des net currently have ■ tenan4 t it is my responsibility to notify the occupant of the
docst s wldc must met br to issuance of ■ Certificate of ry
D
caner or au ori� cal I Ntc
PERMIT NO.
TBD - TO BE DETERMINED 08040144
PER 1"T ISSUE DATE
0872072008
SANITARY NO. CONTROL NO.
Job Description
ADD 60SQ FMRM,MSTRBDRM,BDRM#2& RMDL
KTCHN,LVNG,DINING RM&.BTHRMS
Ft. Floor Area
36227035.
Issued by;
-roofs
Type of Roof
BUILDING PERMrrINFO
ELECT PLUMB MECH
.� Fes- -F-1
$270000 Valuation
Required Inspections
Occupancy'lype
Date �__ -Z_ n
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'{." or better