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08080085a U2 r— CITY OF CUPERTINO DIVISION _ sa��x �QTI©. BUILDING PERMIT BUILDING ADDRESS: PERMIT NO. 22701 SAN JUAN RD ARTISAN BUILDERS 08080085 , SANITARY NO. CONTROL NO. (415) 863-2232 A RC HIIBCT/ENCiNEER: BUILDING PERMiTTNFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION lob Description 1 hereby anrm that I am liceascd under provisions of Chapter 9 (commencing P with Section 70W) of Division 3 of the Business and Professions Code, and my license is SHED ROOF FRMNG /WALL & H EADERS AS RQU ' D in full form and effect. / D' . f-ICCnEC�Q+ aSa f.,lc- � Date A ! — Contractor U ARCHITECT-S D TION I understand my plans shall be used as; public records Licensed Professional OWNER -BUILDER DECLARATION 1 herby arnrm that I am exempt from the Contsacices License Law for the following reason. (Section 7031.5, Business and Professions Cafe: Any city or county which rcquiros 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 he is licensed to the the Contractor's License Law (Chapter 9 Sq. Ft. Floor Area Valuation that pursuant provisions or $10 0 (commencing with Section 7000) of Division 3 of the Business and Professions Code) or that he is exempt dietcfrom and the basis for the allc rd exemption. Any violation of 34217080 `°�� Number Occupancy Type Section 7031.5 by arty applicant for a permit subjects the applicant in a civil penalty of not in= than (ss fire hundred dollars oo). ❑ 1, as owner of the property, or my employers with wages as their sole compensation, Required Inspections will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business and Professions Code: The Conuactor's I-imnse Law does trot apply to an owner or property who builds or improves tbt7eon, and who does such wort himself or through his own employers, provided that such improvements are not intruded or offered for sale. If, however, the building or impmvernent 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 saha)_ ❑ 1. as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Professions Code:) The Ceauactors U- ccnse Law does not apply to an owner of property who builds or improves dwreon, and, who contracts for such projects with a contraebr(s) licensed pursuant to the Contactors License Law. ❑ i am exempt under Sec , B & P C for it" reason Owner - Date - WORKERS COMPENSATION DECLARATION i hereby alarm under penalty of perjury one of the following declarations: ❑ 1 have and will maintain a Certificate of Consent to self -Insure for Worker's Compen- sation, as provided for by Section 3700 of the Labor Code, for the performance of the. work for which this permit is issued. ❑ I 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 Worker's Compensation Insurance carrier and Policy number are: Carrier 2 1 001 53�0� PolicyNo.:ST► - '�_y1I� CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars (S I00) or less.) I certify that in the performance of the work for which this permit Is issued. i shall net employ any person in any manner so as to become subject to the Workers' Compensation Laws of California Date Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code, you must forthwith comply with such provisions or this pcaniL shall be deemed revoked CONSTRUCTION LENDING AGENCY i hereby affirm that throe is a constniction lending agency for the performance of the work for which this permit is issued (Sec- 3097, Civ. C-) L endefs Name , Lenders Address I 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 (We) agree to save, indemnify and keep harmless the City of Cupertino against j liabilities, judgments, costs and expenses which may in any way accrue against said City consequence of the granting of this permit. iin APUNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT PL.I Issued by: Date < 2z1 S GULATiONS, —I Z- eg 0 g Re -roofs Type of Roof Sig Applicant/Contractor . Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or rut= building occupant store or handle hazardous m■terial as defined by the Cupertino Municipal Code, Chapter 9.17, and the Health and Safety Code, Section 25532(a)? All roofs shall be inspected to any roofing material being installed. ❑ Yea No 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 device which emH haaallom air contaminants ayd"Cfined by the Bay Area Air Quality Management all new materials for inspection. District? ❑Yes No (�/ I have mad die hazardous materials mquirtmcnis under Chapter 6,95 of the Califor- nia Health & Safety Cede. Sections 25505, 25533 aid 25534.1 understand that if the bwnld-wg does not currently have a tenant, that it is my responsibility to notify the oaupant of the rcquiremenZM be met prior to issuance of a ccunatc or 'C Signature of Applicant Date � All roof coverings to be Class'A"' or better Date . Owneor