06110066CITY OF CUPERTINO,,
BUILDING DIVISION PERIVIITr'r
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BUILDING ADDRESS: , n ��
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D - TO BE DETERMINED
PERMIT NO.
06110066
OWNER'S NAME:
PERMIT ISSUE DATE
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SANITARY NO. CONTROL NO.
ARCHIECTIENGINEER
BUILDING PERMITiNFO
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LICENSED CONTRACTOR'S DECLARATION
Job Description
i hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Divison 3 of the Business and Professions Code, and my license is
S FDWL • 2 9 4 8 ' GARAGE- 4 6 9 ' COVERED PORCH • 120,
in full fora and effect
License Class LIc•+
56.38 X 469 = 26,442.22 38.51 X 120 = 4621.20
Date Contraaar
ARCHI ECfSDECLARATION
PPERMIT APPL EXTENDED TILL 11 / 15 / 07 PER GREG
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit m conslmct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that be is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$ 6 6 3 0 2 5
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
P Y YP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (S500).
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code: The Contractors LIanse Law dots not apply to an owner of
property who builds or improves thereon, and who does such wort himself or through his
own employes, provided that such improvements are not intended or offered for sal.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
owner of the property, am exclusively contracting with licensed contractors to
nss the project (Sax 7044. Business and Professions Cole:) The Contractors Li -
aurae Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractar(s) licensed pursuant to the Contactors
License Law.
❑ 1 am exempt under Sera , B & P C roe . reason
D 11
I hereby affirm under p"ty of perjury one of the (o ng deciaradons
❑ I have and will maintain a Certificate of Consent to self-insum for Workers Compen-
sation, 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 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 Worker's Compensation insurance artier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF DCEMP ION FROM WORKERS
COMPENSATION INSURANCE
(This section need not be completed it the permit is forone hundred dollars (S 100)
or less.)
I certify that in the performance of the wprk for which this permit is issued. I shall no
employ any person
Id
become sub W the Workers Compcnsa n provisions of the Code y u must
forthwith mply with such Provisions or this permit shall be deemed revoked.
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 (Sere. 3097, Civ. C.)
Lenders Name -
Lendees Address
I certify that I have read this application and sate that the above information is
'
cmeM I agree to comply with all city and county ordinances and stale laws relating to
building construction, and hereby awhorim 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
liabilities, judgments, costs and expenses which may in any way accrue against said City
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in of the gmnting of this permit
APPLICANT UNDERiSTANDS AND WILL COMPLY WiTH ALL NO POiNr
Issued by: Date
SOURCE REGULATI NS.
-roofs
of Roof
igirtluit of ApplianUCon Dale
US MA Dls RE Date
Will the applicant or Lure building occupant store or ndle hazrdous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, section 25532(,)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes [I No
If a roof is installed without first obtaining an inspection,agree to remove
Will the applicant or future building occupant use equipment or devices which
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emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Disuict7
❑Yes ❑No
1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cam, Sections 25505. 25533 and 25534. l understand that if the building
don not
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