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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUIt DITVpl�Rss
HOMESTEAD
PERMIT NO.
RD
TBD — TO BE DETERMINED
07080140
10/29/2007
PHONE:
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
i hereby affirm that 1 am licensed under provisions of Chapter 9 (commoncing
with Section 70DO) of Division 3 of the Business and Professions Code, and my license is
T.I.—SUBWAY SANDWHICH, ELECTRICAL,MECHANICAL,
in full force and effect.
License Class Lie. r
PLUMBING.
Dale Contractor
ARCHITECTS DECLARATION
i understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following mason. (Section 70315, 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
he is licensed to the of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that pursuant provisions
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 5 5 0 0 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (ssao).
316 0 3 0 4 4AV8
❑ 1, as owner of the property, or my employees with wages as their sole cmnp en"don,
Required Inspections
will do the work and the structure is not intended or offered forsak (Sec. 7044, Business
and Professions Code: The Contractors License Law does 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 art not intended or offered forsale. Jr.
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.),
L 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 sort projects with a comractor(s) licensed pursuant to the Contractors
License Law.'
❑ 1 am exempt under Sec , B &11 P C for This mason
1 hereby affirm under penalty of perjury one of the following declarations:
❑ Than and will maintain a Certificate of Consent to self4risure for Worker'sCompen-
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 Worker's Compensation lnsurana, 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 artier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPITON FROM WORKEPET
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S100)
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
become subject to the Worker's Compensation provisions of the Labor Code you must
forthwith comply with such provisions or this pernit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
1 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
'
.
Lenders Address
1 certify that 1 have read this application and state 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
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND L COMPLY WITH ALL NON-P TNT
Issued by: Date
SOU
HAZARDOUS MA ALSDISCLOSURE
Wi11 the applicant or future building occupant store or handle hazardous material
-
as defined by fhe Cupertino M pal Code, Chapter 9.12• and the Health and Safety
Code, Section 25532(a)T
❑ Yeses
All roofs shall be inspected prior to any roofing material being installed.
'Idin
If a roof is installed without first obtaining an inspection, I agree to remove -
Will the a licant or futum oav
Pp 8 pant use equiprncol or ekvices which
,
emit hazardous air contami is defmcd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes Nu
i have read the hazardous materials requirements under Chapter 6.95 of thc Califor-
nia Health & Safety Code Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a tenant. that it is my responsibility to notify the occupant of the
requimmems which t be met prior 'ssuance of a Ccnificatc of `rap�a��/o-
Signature of Applicant Date
C_o ,_ o
. All roof coverings to be Class "B" or better
--—
Owner or authorized aeenl Da