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CITY OF CUPER'11NUa
BUILDING DIVISION PERMIT ���'�' �� � -W-0- 4�IAAT.1 :
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BulLntr�a�� Ess�OREE AVENUE TBD - TO BE DETERMINED PERMIT 07080180
OWNER'S NAME: PERMIT ISSIIE DATE
SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG SECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
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.
License Class Lie. a
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I 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 stature
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 Businessand Professions Code) or
that he ls exempt therefrom and the basis for the alleged exemption Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars WOO).
❑ 1, as owner of the property, or my employees with wages as thew 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 to an owner of
property who builds or improves thereon, and who does such wort himself or through his
own employees, provided that such improvements are not intended or offered forsale. 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
saleJ.
1, as owner of the property, am exclusively contracting with Bcensed contractors to
nstruct the project (Sec. 70", Business and Professions Code:) The Contrary's Li-
ccnse Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licamd pursuant to the Contractors
License Law.
❑ I am
DECLARATION
I hereby affirm under penalty of perjury one of the following drdaations:
❑ 1 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
wort; for which this permit is issued
I 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 Workers Compensation Insurance carrier and Policy number arc:
Carrier. Policy No.:
CERTIFICATE OF EXPMP ION FROM WORKERS'
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars ($I00)
or Icss.)
I certi(y that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any in so as to �me subject to the Workers' Compensation
Laws of Califomia. Date.
Applicant L.1.5.
NOTICE TO APPUCAA7. If, a er 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 pcanit shall be deemed revnkcd.
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-)
Lenders Name
Lenders Address
I certify that I 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 construction. and hereby authorize mpmscmatives 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, judgmems, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNQERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOUR
Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupantstorc or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes A No
Will the applicant or future building occupant use equipment or devfcrs which
emit hazardous air contaminants as defined by the Bay Area Air Quality Maragemeal
District?
❑ Yes Nu
1 have read the hazardous materials requirements under Chapter6.95 of the Califor-
niaHealth & Safety Code, Scctions25505.25533and 25534.1understandthat ifthe building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which be reel prior to issuance of a Certificate of Occupancy.
-1121L7
Date -
Job Description
HOUSE DEMOLITION -NO TREES TO BE REMOVED
NEED CONTRACTOR INFO
Sq. Ft. Floor Area
3 7 519 015 ?ftl Number
Issued by:
Re -roofs
of Roof
valuation
$5000
Required Inspections
Occupancy Type
Date
',K
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