07120118rY OF CUPERTT
BUILDING DIVISION
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BUILDING gIZDg,Fs SANTA PAULA AVE
PFRMrr NO.
TBD — TO BE DETERMINED 1 07120118
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SANITARY NO. CONTROL NO.
ARCHTIECT/ENGINEER
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect.
License Clan Lic. N
Date Contractor
ARCHIIECPS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alTiro that I am exempt from the Cono-wor's License Law for die
following reason. (Section 7031.3, 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 In file a signed sufement
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that be is exempt therefrom and the basis for the alleged exemption. Any violad'on of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
men more than five hundred dollars (S500I
❑ L as owner of the property, or my employees with wages as their sole compensation,
will do the wort, and the structure h not intended or offered for sale (Sec. 70M. Business
and Professions Code.- The Contractors License Law does not apply to in owner of
property who builds or improves thereon, and who does such work himself or through his
owns 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 ow= -
builder will have the burden of proving that be did not bond or improve for purpose of
VL as owner of the property, am exclusively contracting with li a used contractors to
construct the project (Sex:. 7044. Business and Professions code:) The contractors Ll-
cause Law does mot apply to an comer of property who builds or improves themon. and
who contracts for such projects with a contractor(s) licensed pursuant to the Contraeties
License LAW.
❑ 1 am exempt u Sx . B & P C for this reason
DECLARATION
I hereby affirm under penalty of perjury One of the following declarations:
❑ 1 hsve and will maintain a Certificate of Consent to self-Inawe 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.
❑ 1 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 Worker's Compensation Insurance artier and Policy number am:
Carrie. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need riot he completed If the permit is forone hundred dolars ($100)
or less)
1 certify slut in the performance of the work for which this permit Is issued. 1 shall not
employ any person in any manner so to the Workers' Compensation
Laws of Califomi�//g�� 7 �
Applicant ='LT�� , Gk
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2
NOTICE TO APIrCA1tlf. after maMg this Ccnifiate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pcmnft shail 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
I 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 authorise representatives of this city to enter upon the
above -mentioned pmperry 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.
APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURC
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or faturc building occupant store or handle hazardous material
as defined by the Cupertino Mucci I Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑ Yes o
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
Distict7
❑Yes C1 IN.
I have read the hamrdons matrials mquirement.s under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that if the building
does not cop9dy have a retant. that it is my responsibility to ratify the occupant of the
rcyuire
PROPOSED DETCHED GARAGE, 84(
Job Description
Floor Area
Issued by:
Re -roofs
Type of Roof
Required Inspections
PERMIT INFO
Valuation
Occupancy
Date j
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 materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better