08110072 CITY OF CUPERTINO ZII� :
BUILDING DIVISION PERMIT `
PERMIT NO.
BUILDING ADDRESS:
PERMIT ISSUE DATE
OWNER'S NAME:
t0 r S A CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
D D O D
v p p LICENSED CONTRACTOR'S DECLARATION Job Description
y m C 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
t Z t�J with Section 7000)of Direst 3 of the Business and Professions Code,and my license is
Zr in full fore and effect NEW STUDIO AREA, ENLRGMNT MSIR BEDRM& EXT BEDRM
j tj 2 License Clan LK•k
3FO Date factor DECLARATION
INCLD W,CLSET&BATHRM) 345SQ
' ARCHITECT'S
4 l understand my plans shall be used as public records
�yU
O y Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
cc following reason.(Section 7031.5,Business and Professions Code:Any city or county
c$ alter,improve,demolish,or repair any structure which requires a permit to construct,
prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
_
4,< Ft.Floor Area
_< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
I•- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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 of APN Number Occupancy Type
not more than five hundred dollars(5500)• 31632037 . 00
❑I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not 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 are not intended or offered for sale.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 Contractor's U.
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a conuactor(s)licensed pursuant to the Contractor's
License Law.
C3 1 am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
PI ham and will maintain a Certificate of Consent to self-insure for Workers Compen-
ton,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 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 Compensation insurance carrier and Policy number am:
Cartier. Policy .:
CERTIFICATE OF EXEMPTIO OM W ERS'
COMPENSATION I RAN
(This section need not be compielcd• permi for one hundred dollars(5100)
M-
or less.)
I certify that in the performance of ch this pe it is issued,I shall not
employ any person in manner mg-2 t to Workers'Compensadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT/f.after making this C iGcac of Exemption,you should
become subject to the W is Compensation p isions of the Labor Code,you must
Z forthwith comply with fuch provisions or this permit shall be deemed revoked.
0
Zo CONSTRUCTION LENDING AGENCY
t
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.)
W A Lenders Name
Z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
LL E~" correct.I agree to comply with all city and county ordinances and stale laws relating to
0 V building conswction,and hereby authoris resentatives of this city to enter upon the
>W above-mentioned property for inspection s
a (We)agree to save,indemnify d harmless the City of Cupertino against
liabilities,judgments,costs and expo w 'h may in any accrue against said City
V`Z inconsequence of the granting of is pc u' Date
r. APPLICANT UNDERSTA ANLY WITH ALL NON-POINT Issued by:
SOURCE REGULATI
14—z Re-roofs
Signature ofAppliCan onlractor °are Type of Roof
AZARDOUS MA ALS DISCLOSURE yP
Will the apo(icant or future building occupant store or handle harsrdous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? / All roofs shall be inspected prior to any roofing material being installed.
❑Yes /&<0
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 harardous air contaminants az defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
I have read the hazardous rials re iremcnts under Chapter 6.95 of the Califor-
nia Health&Safety Codc,Secti 25505. 3 .1 understand that if the building
does not currently have a ten y respo hbility to notify the occupant of the
requirementsw' must twijs arc f a Certificate of Occupancy. Signature of Applicant Date
All roof coverings to be Class'n"or better
Owner or authori d agent Date