07020076 CITY OF CUPERTINO
BUILDING DIVISION PERMITS Z �RMATIQ
BUILDING ADDRESS: PERMIT NO.
OWN ASTEVENS =01N RD R11qK0—
-"'WARINKO BALDE �M-P``B)04,02007 CONTROL NO.
ARCHI I1 CT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
j z0 LICENSED CONTRACTOR'S DECLARATION Job Description
p I 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
o. in full force and effect.
z, License Class Lic.B REVISION: EXTERIOR STAIRS AND WINDOWS AT THE
"Lu Lu Date Conractor
ARCHITECTSDECLARATIONLIVING ROOM, KITCHEN, & MASTER BEDROOM. ADDING
za I understand my plans shall he used as public records
1SKYLIGHT'S. ADDING BALCONY AND BALCONY DOORS.
V
L I- Licensed Professional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
j O 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
L y prior to its issuance,also requires the applicant for such permit to file a signed statement t,
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area Valuation
-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that be is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Kcupancy Type
not more than five hundred dollars($500).
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Convector's License Law does not apply to an owner of �l p
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.).
tom.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
I am exempt under Sec. B&P C for this reason
Owner AAA2" Date `D
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
hire and will maintain a Certificate of Consent to self-insure for Worker's Compen-
.on,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 am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any"A
so as to become subject to the Workers'Compensation
Laws of Calif to
Appy &;ej
NOTICE 16 APPLICANT:If,after making this e t emption,you sliould
become subject to the Workers Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
C
CONSTRUCTION LENDING AGENCY
4 1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(See.3097,Civ.C.)
Q Lender's Name
z Lender's Address
0 1 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
Vbuilding construction.and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
W
W (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit. '3
►+ APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC GULATIpN
Re-roofs
Sigfiatitre of Applicant/Contractor Date Type of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will 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)? All roofs shall be inspected prior to any roofing material being installed.
0Yes Bwo-
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants as defined by the Bay Area Air Quality Management all new maerials for inspection.
strict?
El Yes ®�
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
docs not currently have a ten t.the ' 's my responsibilily to notify the occupant of the
requirem hienm t r cc 6aCcni&ateof0cupancy. 07 Signature cif Applicant Date
4,A-94^A� All roof coverings to be Class"B"or better
Owner or authorized agent Date