07100201 CITY OF CUPERTINO
BUILDING DIVISION PFs,R7 sty[ �4A�J .e
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BUILDING ADDRESS: PERMIT NO-
22204 VIA CAMINO CT TBD — TO BE DETERMINED 07100201
OWNER'
11/06/2007
PHONE: SANr1ARY NO. CONTROL NO.
ARC HriF.Ci/FN G I NEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 o LICENSED CONTRACTOR'S DECLARATION Job Description
m I hereby afli o
1 am licensed under provisions of Chapter 9(commencing
z with Section 7000)o vW.43oftheBusmessandProf andmylicensets KITCHEN & FAMILY REMODEL W STRUCTURAL. THE
y in fuB force and e
License ru V Lie.+ UILDING WORKS,GEN'L CONTRACTOR, PD NEW BSL
Date ARCHITECT'S� 0 10/2 9/0 7 $10 7 . 0 0
err 1 my planshag s be used as public records
U
a
y Licensed Professional
OWNER-BUTLDFR DECLARATION
t I hereby affirm that I am exempt from the Contractor's License Law for the
00 following mason-(Section 7031.5,Business and Professions Code:Any city or county
m(ii which requires a permit to consumM alter,improve.demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
< that he is licensed pumianl to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $6 5 0 0 0
Valuation
5 (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 or
Section 70315 by airy applicant for a permit subjects the applicant to a civil penalty of Number Occupancy Type
not more than rive hundred dollars(SSOQ} 3 2 6 4 6 0 0 8 AFF
71 L as owner of the property,or my employees with wages as their sole compensation,
will do the work and iht structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractors License Law does not apply to an owner of Required Inspections
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).
❑L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of properny who builds or improves thereon,and.
wbo contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑1 am exempt under Sec B R P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm trader penalty of perjury one of the following declarations
ere and will maintain a Certificate of Consent to self-insure for Workers Compm-
•on,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 Workers Compensaion Insurance,as required by Section
370D of the Labor Code,for the performance of the work for which this permit is issued '
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSAT10N INSURANCE
(This on n d n be completed if the permit is for one hundred dollars($100)
or less.)
1 artifv Ihat' ce of the work for which this permit is issued,I shall not
employ any
Applicant
NOTICE TO A PC If,after making this Certificate of Exemption,you should
become subject w LIthe W s Compensation provisions of the Labor Code,you must
2 forthwith comply with such lions Or this permit shall be deemed revoked.
4 O CONSTRUCTION LENDING AGENCY
.n-r 1 hereby affum that there is a construction lending agency for the perforrna of
Ti ' the work for which this permit is Issued(Sec.3097,Civ.C.)
Gl 0 Lenders Name
Z Lenders Address
Q 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 repnsscntatives of this city to enter upon the
LL) shove-men tad propcny r irtspcetion purposes
yGL (W) gmc ease, ndemnify and keep harmless the City of Cupertino against
,y liabilities, n oats d expcases which may in any way accrue against said City
in conseq c C nit g of this permiL
61
Re-roofs
Signuureo Applicant/Co for DaIV
GUs TERIALS DISCLOSURE Type of Roof
V1r1IILhCappljC&nt future 'ding occupant pore or handle harardous material
as&ruled by the Cupeni M 'pal 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 No
Will the applicant or future 'Iding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emir hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes No
c th ardousmaterialsrequiremensunderChapter6.95oftheCalifor-
nia H S tyC Sactiorys 505,25533 and 25534.1 understand that if building
does n ha a tenant iL is my responsibility tc notify a ant nr the
All roof coverings to be Class"B" or better
Owner r au orizcd gent Iate