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CITY OF CUPERTINO
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BUILDING DIVISION PLi'J�r1L1nT�y�7-�
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BUILDING ADDRESS:
PERMIT NO.
:
SANITARY NO. CONTROL NO.
(408)782-3102
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70o0) of Division 3 of the Business and Professions Code, and my license is
S FDWL— ONE . STORY 2 r 0 6 4 ' /BASEMENT 1,475 '
in full and effect. Lice
GARAGE 429' —SANITARY SUNNYVALE'S JURISDICTION
Date Contractor—
ARCHITECT'SDECCLARATION
PERMIT APPL EXTENDED 02 / 07 / 07
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors 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, demnlLch, or repair any structure
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 Contractors License Law (Chapter 9
Business
Sq. Ft. Floor Area
$ 7 5 8 6 5 5 Valuation
do (commencing with Section 7000) of Division 3 of and Professions Code) or
that,he is exempt therefrom and the basis for the alleged exemption. Any vlolalion of
3 7 5 2 8 0 0 4 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 (SS()0).
.
1, as owner of the property, or my employees with wages as thew sole compen aidon,
Required Inspections
will do the work. and the structure is not intended or offeed for sale (see. 7044, Business
and Professions Code. The Contractor's License Law does not apply to an owner of
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property who builds or improves d¢mon, and who does such work himself or through his
own employes, 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.).
10 I, as owner of the property, am exclusively contracting with licensed contractors to
diltistruct the project (Sec. 7044. Business and Professions Code:) The Contractor's U.
cerise Law does not apply to an owner of property who builds or improves thereon, and .
who contracts for such projects with a contractors) licensed pursuant to the Conu actor's
License Law.
❑ I am
�- Date f 3•-
-
WORKER'S CIDMPENSA77ON DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self -Insure for Wr ftes Compen-
sation, as provided for by Section 3700 of the Labor Code, 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
3700 of the Labor Code, for the performance of the work for which this permit is issued
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be 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, 1 shall not
employ any person in any manner u to become subject to the Workers' Compensation
Laws of Californ arm � T
T
Applicant. 9 4,
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 state that do above information is
torten. I 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
.hove -mentioned properly for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in anyway accrue against said City
in consequence of ncc granting of this permit,
All roofs shall be inspected prior to any roofing material being installed.
s ❑ Y(ANo
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 hvirdous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yes ANo
I have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health & Safety Code. Sections 25505. 25533 and 25534.1 understand that if the building
dues not currently hale a tenant, that it is my responsibility to notify the occupant of the
require= which be met priortaissuariccofaeenifrcateofOccupanr:y.
Signature of Applicant Date
' p" —�� —�
All roof coverings to be Class "B" or better
Owner or authorized agent Date