09090116 CITY OF CUPERTINO
BUILDING DIVISION PERMIT + � T •C' 3RtMTaNp
PERMIT NO.
BUILDING ADDRESS:
22284 PALM AVE RYOJI WATANAB
PERMIT ISSUE DATE
OWNER'S NAME:
44 VVE; S A CONTROL NO.
nONE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
aad pp LICENSED CONTRACTOR'S DECLARATION Job Description
j w CI hereby affirm that I am licensed under provisions orC
Chapter 9(commencing
Z ty with Section 70(0)of Division 3 of the Business and Professions ode,and my license is
y in full force and effect. REMODEL(5 2 6) STUDY,LAUNDRY RM, POWDER RM#5;ADD 2
Dns License Class Lic•M SKYLIGHTS EA. SMALLR THAN 10SQ.
G F in Dam Contractor
LQ ARCHITECTS DECLARATION
4 g< 1 understand my plans shall be used as public records
ryU
4 C N Licensed Professional
V2 3 OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractoes License Law for the
C o O following reason.(Section 7031.5,Business and Professions Code:Any city or county
-12 P 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 Area Valuation
G that he is licensed pursuant to the provisions of the Contractor's Liccnsc Law(Chapter 9 iq.Ft.Floor
yt- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $40000
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 rive hundred dollars(S50o). 35704032 . 00
❑1,as owner of the property,or my employees with wages at their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Cade:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such wort himself or through his
own employees,provided that such improvements arc not intended or offered for sale.If.
however,the building or improvement is sold within one year of completion.Ute 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 Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a conuwwr(s)licensed pursuant to the Contractor's
License Law.
❑1..7pt under Sec. B&P C a rc
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure Cor 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.
❑1 have and will maintain Workees 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:
Cwr1ert Policy No.:
CERTIFICATE OF EXF-MPRON FROM WORKERS'
COMPENSATION INSURANCE
(This section need Trot be completed if the permit is for one hundred dollars($100)
or less)
I certify that in the performance of the work for which this permit is issued,l shall not
employ any person in any manner so as to become sgbject to the Workers'Compensation
A
NOTICE TO APPLlCA :lf,aft r making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z m'" CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
IYm the work for which this permit is issued(Sec.3097,Civ.C.)
W QL-endices Name
P. Lender's Address
U O I certify that I have read this application and state that the above information is
LL H correct.I agree to comply with all city and county ordinances and state laws relating to
C U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes
W
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
,E"y liabilities,judgments,co and expenses which may in any way accrue against said City
U Z in consequence of the ting of this permit. Date s l/
�+ APPLICANT UN ANf�S ND WIL Ci9MPLY WITH ALL NON-POINT Issued by:
SOURCE REG NS.
lS Re-roofs
Signature of A li U ontractor Date
AZARDOUS M ALS DISCLOSURE Type of F.00f
Will the applicant or future buil mg occupant store or handle hazardous material
as defined by the Cupertino M cipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
u
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or Tutbuilding occupant use equipment or devices which
emit hazardous air contaminants domed by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
Lrcquim=n
ve read the ars materials requirements under Chapter 6.95 of the Califor-
Sarcty C Sections 25505,25533 25534.1 understand that if the building
rrently a in that it is my risibility to notify the occupant of the
h be ph rto nr.Ccrtificaeor cu Signature of Applicant Date
ur gent
Dam All roof coverings to be Class or better