07070016CITY OF CUPERTINO
BUILDING DIVISION PERMIT
T
YlAI�
BUILDING ADDRESS:
PERMIT NO.
1
—
OWNER'S NAME:
P A
PHON
S CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(1(1) of Division 3 of the Business and Professions Code, and my license is
in full force and cffe S'•
T.I.-EXTERIOR ENTRY MODIFICATION
LiccnsLic.
c Class #
Date Contractor �•
ARCHrrECTS DECLA A ON
1 understand my plans shall he used as public records
Licensed Professional �
OWNER -BUILDER DECLARATION
I hcrchy affirm that 1 am exempt from the Contractor's License Law for the
following reason- (Section 7031.5, 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
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 70(X1) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
ecupancy Type
Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
31609037
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
P
will do the work and the structure is not intended or offered forsalc (Sec. 7044, Business
and Professions Code: The Conuactor's License Law does not apply to an owner of
9
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.).
❑ I, 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 contractor(s) licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec- . B & P C for this reason
Owner-._. -- ----:..:z—_- --__-- ---Date---
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Cote. 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
370D of the labor Code, for the performance of the work for which this permit is issued.
'
My Workers Coptpens u'gp Insutantt carrier and Policy number are:
Carrier:
EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (S190)
or Icss)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California Date
Applicant '
NOTICE TO APPLICANT: 11, 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
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
,
Lender's Address
I certify that 1 have read this application and state that the above information is
correcL I 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 UN STANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
DaIJ
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
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
Code. Section 25332(a)? ;
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes No
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 defined by Nc Bay Arca Air Quality Management
all new materials for inspection.
District?
❑ Yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & SafetyCodc, Sections 25505, 25533 and 75534.1 understand that if the building
docs not curen have a tenant. Nat it is my responsibility to notify the occupant of the
requi issuancc of a Certificate of Coca cy.
Signature of Applicant Date
-
All roof coverings to be Class "B" or better
Owner or authorized agent „C
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
R'S NAME:
ARCHITECT/ENGINEER:
zo LICENSED CONTRACTOR'S DECLARAI IUN
F I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
UW with Section 70(X0) of Division 3 of the Business and Professions Code, and my license is
y in full force and effe S`
Z License Class .-- Lic• # L
p Datc Contractor
~ ARCHITECTS DEC A O
-� I understand my plans shall be used as public records
;a
•u
H Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
j o following reason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
y 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 Contractor's License Law (Chapter 9
- $ (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
C 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
not more than five hundred dollars ($500).
❑ 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
and Professions Code: The Contractor's License Law does not apply m 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.).
❑ I, 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, Ind,
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under Sec. B & P C for this reason
V
Job Description
T.I.—EXTERIOR ENTRY MODIFICATION
Sq. Ft. Floor Area
31609037
Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
] I have and will maintain a Certificate of Consent to self -insure for 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.
111 have and will maintain Worker's 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 Cg►��pensatiInsyrance carrier and Policy number are:
Carrier. s. L� ti Policy No.: 6Ay�6
CERTIFICATE EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he 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, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date —
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's 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 stale that the above information is
cored 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 UNDARSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by
Signature of Applicant/Contractor �•w
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Section 25532(a)? r
❑ Yes No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes 1V�
I have read the hazardous materials requirements underChapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not cureno have a tenant, that it is my responsibility to notify the occupant of the
mauirchwots vfniik must beiva6rri0F4kissuancc of a Certificate of Occupancy. `
Owner or
Re -roofs
Type of Roof
valuation
Type
Required Inspections
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
all new rr aterials for inspection.
Signature of Applicant
All roof coverings to be Class "B" or better
Date