09060157 CITY OF CUPERTINOTIO
r
BUILDING DIVISION PERMIT �* + � t6
BUILDING ADDRESS:
PERMIT NO.
`tER'S NAME: PERMIT ISSUE DATE
PHON : fteH 1301: NE)RT -N ST
SAN CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
REMODEL 2/0 SQ FT TO
Boa LICENSED CONTRACTOR'S DECLARATION KITCHEN, 144 SQ FT TQbM�ption
v F- I hereby affirm that I am licensed under provisions of Chapter 9(commencing T r r T ryT
Z Ed with Section 7000)of Division 3 of the Business and Professions Code.and my license is
t ro„ in full force and effect. Q
? License Claw Lic.1t
Date i /7/- .+�C' Contracto
ARCHITECTS DEC RATION
7 < 1 understand my plans shall be used as public records
106
H Licensed Professional
t y
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
:a 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
?Z y prior to its issuance,also requires the applicant for such permit to file a signed statement
=c that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft Floor Area Valuation
F- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he 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 APi 1 Number Occupancy Type
not more than five hundred dollars(5500).
❑1,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(See.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q
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.).
❑1,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.
❑1 am exempt under Sec. B&P C for this reason
nr Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workces 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 Worker's Com ensation Insurance carrier and Polity nu ber am:
Cartier �.J✓1 Policy No.: ����2�7 ���
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 certifv that in the performance of the work for which this permit is issued.1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant -
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
Oforthwith comply with such provisions or this permit shall be deemed revoked.
2:" CONSTRUCTION LENDING AGENCY
rA
— I hereby affirm that there is a construction lending agency for the performance of
:4> the work for which this permit is issued(Sec.3097.Civ.C.)
4Q Lender's Name
1.
z Lender's Address
Q I certify that I have read this application and state that the above information is
y t"'
correct.I agree to comply with all city and county ordinances and state laws relating to
DV 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
rA liabilities,judgments•costs and expenses which may in any way accrue against said City
J Z in consequence of the granting of this permit.
APPL NT UNDERSTAND ND
AWILL COMPLY WITH ALL NON-P INT Issued by: Date `v
S RE lP NS.
_� �� Re-roofs
Signature of icant/Contractor tatc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haiardous material
as defined by the Cupertino 7N.
1 Code.Chapter 9.12,and the Health and Safety
Section 25532(a)7 All roofs shall b:inspected prior to any roofing material being installed.
❑Yes
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
emit hazardous air contaminants astoed by the Bay Area Air Quality Management all new material;;for inspection.
District?
C]Yes No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Hcalth&Safety Codc,Sections 25505.25533 and 25534.1 understand that if the building
doestnotu have a tenant.that it is my responsibility to notify the occupant of the
requts icnm tby tprior m eracen;fieatceroccup . Signature of Applicant Date
12-6;10
Owner orautharizcd ret Da All roof coverings to be Class';.''or better