06010127CITY OF CUPERTINO
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BUILDING ADDRESS: ,sw
PERMIT NO.
THOMAS E HARRIGNTON
06010127
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PERMIT SSUEDATE
PHONE:
SANITARY NtQ L NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 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
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License C enacClass o
Date Contractor
PEETS COFFEE SHELL 1 774' /TRASH ENCLOSURE
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ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I 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
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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
,
that he is exempt therefrom and the basis for the alleged exemption Any violation of
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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 (f500).
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❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure Is not intended or offered for sale (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 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 due burden of proving that he did not build or Improve for purpose of
sale.).
9 1, as owner of the propeny, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor' Li-
cense Law does not apply to an owner of property who builds or improves thereon. and
who contracts for such projects with a eontnetor(s) licensed pursuant to the Contractor'
License Law.
❑
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 370D 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
370D of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEMPI70N FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($I00)
or less.)
I cenify that in the performance of the work for which this permit is issued, 1 shall not
employ any
shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
l hereby affirm that there is a convection 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
correct. I agree to comply with all city and county ordinances and state laws relating to
building convection, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes.
(Wc) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, toss and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLIC U RSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
Date
HAZARDOUS MATERIALS DISCLOSURE
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 25532(a)?
Yes
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
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
all new materials for inspection.
District?
❑Yes nigD
I have read the hazardous materialsrequiremcnts under Chapter 6.95 of the Califor.
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not c
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