07080249 CITY OF CUPERTINO +CENTRA QTR INEt}RM�'I':ION•:
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
ver
BE
OWNER'S NAME:
Y .2007 CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH
zLICENSED CONTRACTOR'S DECLARATION Job Description
0
'r- I hereby affirm that I am licensed under provisions of Chapter 9(commencing
UW with Section 7000)of Division 3 of the Business and Professions Code,and my license is
o. in full force and effect. REVI S I01` HEATER AND WATER HEATER LOCATION -
3 z License Class Lic•8
o Date Contractor STRUCTUFAL CHANGE
U2 ARCHITECTS DECLARATION
--� I understand my plans shall he used as public records
U
y Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
jo 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 ` Valuation
o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q.Ft.Floor Area
-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
I::- that he is exempt therefrom and the basis for the alleged exemption.Any violation of APN 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(5500).
0 I,as owner of the property,or my employees with wages az their sole compensation, 35702014: . 00
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
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 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 the burden of proving that he did not build or improve for purpose of
sale.).
,'I,as owner of the perty,am ezelusively contracting with licensed contractors to
construct the project .7044.B ;nets and Professions Code:)The Contractor's Li-
cense Law docs not p to an ner =y who builds or improves thereon,and.
who contracts for s h cts rth on ctors)licensed pursuant to the Contractor's
License Law.
❑I am exempt B r s on
Owner Da
KEYS CO ENSATION DECLARATI
I rcb under pe y of perjury one of the following declarations:
I J ve and wit maintainit 'Gcate of Conaent to self-insure for Workers Compen-
sation,as provided for by S 'on 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
Q 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 Polity number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Jjted it the permit is for one hundred dollars($100)
or less)
I certify That in the perfotmano f which this pe i Iemploy any person in any man e subject to the n on
Laws of California.Dale
Applicant 49 4E
NOTICE TO APPLIC • f fft#making this Certificate of Exemption,you should
become subject to th r' 'C pensation provisions of the Labor Code,you must
O forthwith comply wi h prov ions or this permit shall be deemed revoked.
i
CONSTRUCTION LENDING AGENCY
r 4 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.)
QLender's Name
Z Lender's Address
0 1 certify that I have read this application and state that the above information is
H correcL 1 agree to comply with all city and county ordinances and state laws relating to
j U building con coon,and hereby authorize representatives of this city to enter upon the
U above-menu cd props forinspcction purposes
of Cupertinoinst said City
Z in conseq g is permit. Date l ( U
►� APPLIC R DS AND WILL COMPLY WITH O -P Issued by:
SOURC O
Re-roofs
ignat Mnpl;can on or °e� T of R)of /
DOUS MATERIALS DISCLOSURE Type ill the applican r future building occupant store or handle hazardous material
az fi ed by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
dc.Section 25532(x)? All roofs:,hall be inspected prior to any roofing material being installed.
Yes �No
If a roof i:.installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
.:mit hazardous air con 'nants as defined by the Bay Area Air Quality Management all new m iterials for inspection.
District?
O Yrs
I have read the s ma ri rements under Chapter 6.95 of the Califor-
nia Health&Safety C and 25534.1 It
that if the building
docs not currently h t m responsibility to notify the occupant of the
rcyuiremcn ch e i crtificatcmrOccu ancy. Signature of Applicant Date
r�� All roof coverings to be Class"B"or better
Owner o autho •zed g t Date