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CrrY OF CUPERTINO
BUILDING DiV1S10N PEM���
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BUR -DING ADDRESS:
PE IT NO.
18770 LOREE AVE
TBD TO BE DETERMINED
08040161
OWNER'S NAME:
PERMIT ISSUE DATE
SANTIARY NO. CONTROL NO.
ARCHfrECTIENGREER:
BUILDING PERMIT INFO
BLDG PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby afrrm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my licatre Is
DEMO
in full force and effect
L.ieensc Class Lk. N
Dam Contractor
ARCHrfEcrs DECLARATION
I understand my plans WWI be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
i hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031 S, Business and Professions Code: Any city or county
which requires a permit to construct, alter. hnpmve, demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed staremem
chat he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
puraunt provisions
10 0 0 0
(commencing with Section 7000) of Division 3 of the Businesa and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
3 7 515 0 2 5 Number
QCCU
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 (S500).
L 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 inumided or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors Licees License Law donot apply to an owner or
property who builds or improves thereon, and who does such work himself or through his
owe enploycea, provided Utat 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 wjjAm the burden of proving that he did not build or improve for purpose of
sale.)
L u causer of the property, am exclusively contracting with Berried contractors to
construct the pro)= (See. 7044, Business and Professions Codes:) The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon. and,
who contracts for such projects with a conuactor(s) licensed pursuant to the Contractors
L.keese Law.
1 am exempt under Sec B & P C for this reason
Owner ArtTlidw'�I_ ��
COMPENSA71ONDECLARA ION
1 hereby affirm under penalty of perjury am of the following declaradonz
1 have and will maintain a Cert3fhcate 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.
❑ 1 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 Worke's Compensator insurance carrier and Policy number are:
Cartier. Policy No-
CERTIFiCATE OF E EEMPT70N FROM WORKERS'
COMPENSATION INSURANCE
('niis section need not be completed if the permit is for one hundred dollars (S1G0)
or IcsL)
I certify Unit in the performance of the work for which this permit is Lssued. I shall not
employ any person in any manner so� loJ mC subject to the Worker{ Compertsarlon
Laws of California_ Dale 3 C/
/.J
AppBca't —
NOTICE TO APPLICANT: IL after making this Cer ificate 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 damod revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for rite performance of
the work for which this permit is issued (See. 3097, Civ. C.)
- -
Leudcrs Name
'
Lcders Address
I certify that I have read this application and state that the above information is
eorrecL I agree to comply with all city and county ordinances and state laws relating m
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 acme against said LSry
in consequence of the jranting of this pernliL
AP A ERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
R GULATIONS.
Re -roofs
Type Of Roof
Signature V
MA DISCLOSURE
Will the applicant or future building occupant store or handle harardous muerial
as defined by the Cupertino Municipal , Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
Cl Yea o
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
Win the applicant or I t re build"' nt use equipment or devices which
emit hazardous air contaminants as by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes ❑ No
I have mad the hazardous materials requimmrrts under Chapter 6.95 of tit Califor-
raa Health & Safe Codc, Sections 25505. 25533 and 25534. i understand that irtho bolding
does not n have a =L that it Is my responsibility to notify the occupant of the
rcgaircrr,e wi h mast be met prior to issuance of a cetirieite car
Signature of Applicant Date
All roof coverings to be Class''` or better
Date