07040175CITY OF CUPERTINO fsV — I�T
BUILDING DIVISION PERMIT�'���
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BUILT I6:tIMESE_ EBANON DR
TBD — TO BE DETERMINED
PERMIT NO.
07040175
SANITARY NO. CONTROL NO.
ARCHn=/ENGINEFR:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uCENSED CONTRACTORS DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of thc Business and Professions Code, and my license is
NEW S FDWL : 4 311 ' GARAGE: 6 51 ' GAZEBO • 2 2 5 ' PATIO
in full fora and effect
License Class Lk. a
be
Date ConAHriECrSRCDECLARATION
PORCH: 2 62 ' ROOF OVERHANG: 52 8 '
1 understand my plans slall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031 S, Business and Professions Code: Any city or county
which requires 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
that he is licensed to the the Contractor's License Law (chapter 9
Sq. Ft. Floor Area Valuation
pursuant provisions of
Section 7000) Division 3 the Business and Professions Code) or
10 0 9 3 7 5
(commencing with of of
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty or
e,v � Number Occupancy Type
3 4 214 0 0 8
not more than five hundred dollars (1500).
:
❑ I, asowner of the property, or my employees with wages as their sole compensation,
will do the work, and the slrucum: is not intended or offered for sale (Sec. 7044, Business
Required Inspections
and Professions Code: The Contractors License Law does not apply to in owner of
property who builds of improves thereon, and who does such work himself or through his
own employees, provided that such improvements we not intended or offered for salt 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
seek.
1 u owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to in owner of property who builds or improves thereon. and.
who contracts for such pro' cLt with a contractor(s) licensed pursuant to the Contractofs
License Law.
❑ 1
the following declarations:
❑ I hr. a and will maintain a Certificate of Consscm to self -insure for WorkefsCompen.
cation, 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 site work for which this permit is issued.
'
My Worker's Compensation Insurance carrier and Policy number are:
-
Carier. Policy No.:
'EXEMPTION
CERTIFICATE OF FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollaa ($100)
.
or less.)
I certify that in the pu once of the work for which this permit is issued. I shall not
employ any perso 'n
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.)
'
Lender's Name
,
Lender's Address
I certify that I have read this application and sate that the above information is
correct I agree to comply with all city and county ordinances and sate laws relating to
building construction, and hereby authorize representatives of this city to enter upon thc
ahove-mcmionod property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
IiabiliGes, Judgments, costs and expenses which may in any way accrue against said City
in consequence of c granting of this perniL
-
/
APPLICA U STANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date 1
SOUR6f S. O
MATERIALS DISCLOSURE
Type of Roof
Will the applicant or fuuua 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)?
❑Yes VO
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
Will the applicant or future building occupant use equipment or devices which
emit hazardous air conaminanLa as de toed by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes o
I have toad the hazardous materials mquircmcros under Chapter 6.95 of the Califor-
nia Health& Safety CoX Sections 25505.25533and 25534.1understand! that ifthe building
does not cure ha tenenL that