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CITY OF CUPERTINO
PERMIT
BUILDING DIVISION
BUI I cc��A RESS:
PERMIT NO.
�S�S VAI AVE
EARTH BOUND HOMES
07070076
990 RICHARD AVE STE 104
02/08/2008
PHONE:
SANITARY NO. CONTROL NO.
(408) 244-5392
ARCHI'IEC rIENGINEER:
BUILDING PERMrr INFO
BLDG ELECT PLUMB MECH
o a o 0
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
lob Description
P
(Co
I hereby sneer that 1 am licensed under previsions or (commencing
with Section 7000) ol'DL ' 'on 3 of the Business �3 b2 my license is
eorceau effect.Lic.if
S F DWL 2 , 2 4 5 ' GARAGE 4 9 4 '
Licein ol
6 / 9 / 0 8 PETE MOFFAT CONST NO LONGER CONTRACTOR —
Date ARCHrrECisDECLARATION
NEW
1 understand my plans shall be used as public records
CONTRACTOR IS EARTH BOUND HOMES—PD FOR BUS LIC
Licensed Profcssional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.S. Business and Professions Code: Any city or County
which requires a permit to Construct, alley, 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 Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Proressions Code) or
$ 6 8 4 7 5 0
that he is exempt tberefrWa and the basis for the alleged exemption. Any violation of
Number
umer
3 62 05029.W
Occupancy
Type
Section 7031.5 by arty applicam for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (SS00).
❑ 1, as owner of the property, or my employees 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 Contratemea License Law does not apply to an owner of
property who builds orimproves thereon, and who does such work himself or through his
own employes, provided that such improvements are Cot intended or offered for side. 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. 7044. Business and Professions Code:) The Contractors Li-
cense Law does not apply to an owner or property who builds or improves themon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec B & P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ 1 have and will maintain a Catifkate of Consent to self -insure for Worker's Compen.
sation, as provided for by Section 3700 of die Labor Code, for the performance of the
worst for which this permit is issued
❑ 1 have and will maintain Workers 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 Compensatio�n''Insurmce carrier ar ier and Policy number e:
'
Cartier : Nrt� - Policy Na: b t3Q g LfLC, '
CK%�
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
Cnnis section need not be completed if the permit is formic hundred dollars ($I00)
or less.)
I 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' Compensation
Laws of California. Dare
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 permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I 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.)
Lenders Name
Lenders Address
1 certify that I have read this application and stale that the above information is
correct. 1 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
shove -mentioned properly for inspection purposes.
(We) agree to saw, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way scenic against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOUR ER TIONS.
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
emde,sceYes 25532(a)?
All roofs shall be inspected to any roofing material being installed,
Yes �J +Ire
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 defend by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor.
�lit
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Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the buih8
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not sum have a tenant. that it is my responsibility le notify, t oxuP of
re�ch must
of Applicant Date
L
.�'�'.�"'" i Q
All roof coverings to be Class " " nr hettPr