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CITY OF CUPERTINO
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BUILDING DIVISION PERNIIT�
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CRAFTSMENS GUILD INC
Bu"Tcgx W ESTATES DR
080184
:
SANITARY NO. CONTROL NO.
(408)366-1000
ARCHrrEc r/e4GwWt
BUILDING PERMfr INFO
BLDG ELECT' PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
under provisions of Chapter 9 (commencing
I bmeby affirm that I am licensed wri
with Section 701)(1) ofDivision 3 of the Business and Professions Code, and my 'I== h
REVISION: INTERIOR REMODEL & ADDITION
in full force and effect.
License Class Lic.
Date Contractor
ARCHI ECi-S DECLARATION
I wrdcruand my piano "I be used as public records
Licmmed Professional
OWNER -BUILDER DECLARATION
1 botchy affirm that 1 am exempt from the Contractors License Law for the
following resaon (Section 7031-5, Business and Professions Code: Any city or county
which requires a permit to construct. alter. Improve, demolish. or repair any smumum
prior io its issuance, also requires the applicant for such permit to file a signed statement
he is licensed to the of WeContractoes License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant provisions
Section 7000) Division 3 the Business Professions Code)
$ 3 0 0 0 0 0
(commencing with of or and or
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
Seaton 70313 by arty applicant fora permit subjects the appbcart to a civil paulty of
Number
3 6 9 2 2 0 3 3
Occupancy
p y Type
not more than five hundred dollux (sstm).
.�
❑ L u owner of the property, or my employees with wags as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for We (So— 7044, Business
and Professions Gnat The Contractors License Law doer not apply to an owner of
property who builds or improves thereon. and who does such wort himself orthrough bra
own anployom provided that such improvements are net intended or offered for act If,
however, the building or Improvement is sold within one you of completion, the owner -
builder will have the burden of proving that he did not build or Improve for purpose of
sak.).
❑ L as owner of the property, am exclwivcly contracting with Hammed contractors to
construct the project (Set 7044, Business and Professions Code) The Contactors U-
cease Law does not apply to an owner of property who builds or Improves theroon, and .
who contracts for such projects with a comuww*) licensed pwsuaat to the Contractors
License Law.
❑ I un exempt under Sec . B h P C for this reason
Owner Due
'
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I hmc and will maintain a Certificate of Consent to self -insure for workers compar-
sadon, as provided for by Section 3700 of the tabor Code, for the parfarmamz of the
work for which this permit is isuued.
❑ 1 have and will maintain Warners Compensation li murxnce, as required by Section
3700 of the Labor Cade, for the performance of the work for which this permit is issued.
My Workers Compensu)om Insuni carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This secdoa wed not be completed if the permit is for one hudred do0ars MOD)
or less)
1 certify that in the performance of the work for which this permit is issued, I :hall not
employ any person in any maancr so as to become subject to the Wolters' Compensation
Laws of California Date
Appfkae
— —
NOTICE TO APPLICANT: If, alter making this Catifiatc of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with arch provisions or this permit shall be dammed revoked
CONSTRUCTION LENDING AGENCY
I hereby dMn that ditto is a construction lending agency for the performance of
the wort for which this permit is isnued (Scc 3097. Civ. C.)
Lenders Name
Lenders Address
I cetfy diet 1 have read this application and sure that the above Information is
conccL I agree to comply with all city and county oNtnamxs and state laws relating to
.
building construction. and hereby authorize representatives of this city to eater upon the
above-mrntioned property for inspection purposes
(Vita) agme to save, indemnify and keep harmless the City of Cupertino against
flabilitim jodpxnta cow and expenses which may in any way seems against fold City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
lype of Roof
Slgrtatthro of Applican✓Contractor Dee
HAZARDOUS MATERIALS DISCLOSURE
wit the applicant or ruwre building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 2ss3ua)7
All roofs shall be inspected prior tG an roofing material being installed.
P P� Y g g
❑Yes ❑Nor
s
If a roof is installed without first obtaining an inspection, I agree to remove
w10 he applicant or loom building acapam use cgttpnmamt err devices which
emit hazardous air contaminants a derived by the Bay Area Air Quolity Management
all new materials for inspection.
District?
❑ Yes ❑ No
1 have read the hazardous materials rewi ements urxW Cbapter6.95 of the Califor-
nia Health h Safety Code. Sections 25505, 25533 and 25534. I undmitand tnstif the building
does not currently have a tenant- this it is my responsibility to notify the aampant of the
requirements which must be met prior to issuance: of Cadfiesic of Occvpacyc
Signature of Applicant Date
All roof coverings to be Class'n" or better
Date .
Owner or authorized avmt