09010111CITY OF CUPERTINO
BUILDING DIVISION PERMIT
POO
„.
BUILDING ADDRESS:
PERMIT NO.
18770 L REE LVE
MORE L
OWNER'S NAME:
PERMIT ISSUE DATE
PHO
S CONTROL NO.
408)221-0892
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 am licensed under provisions or Chapter 9 (commencing
with Section 7000) of Division 3 or the Business and Professions Code, and my license is
in full force and effect. -
REVIS TRUSS CALCS — ORIG #07070028
License Class Lk. N
Date Contractor
ARCHITECTS DECLARATION
1 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 to construct, alter, improve, demolLsh, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he is Gccnsed pursuant to Lhe previsions 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
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 ($500}
37515025.00
❑ 1, at owner of the property, or my employers 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 Proressions Code: The Contractors License Law does not apply a an owner or
property wbo builds or improves thereon, and who does such work himself or trough 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 impr aw for purpose of
sale.).
[3-T as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Cafe:) The Contractors Li-
cense Law don 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 Contractors
License Law.
❑ 1 am exemp under Sec B & P C for this reason
Owner Date
6WORKEWSZVOPENSATION 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 Workers Compen-
sation, at 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 Irtirtimce, as required by Section
3700 of the Labor Code, (or the performance of the work for which this permit is issued
'
My Worker's Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF FXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need rat be completed if the permit is for one hundred dollars ($100)
or less)
1 certify that in a perfyNance of the work for which this permit is issued, 1 shall not
employ any per
of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Use there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Clv. C.)
Lender's Name
,
Lenders Address
I certify that I 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
building construction, and hereby authorize represantstives 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
in consequence of the granting of this Perm IL
APPLICANT(UNDEWANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE RE LA NS. 7/
`� /C 5
I
Re -roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
—
Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Mu icip ode. Chapter 9.12, and the Health and Safety
Code, Section25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
[:]Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as de( by the Bay Area Air Quality ManagcmcnL
all new materials for inspection.
D strict?
❑ Yes o
1 live read the harardrxs materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cade, Section 25505. 25533 and 25534.1 whdersiand that if thc building
does not cunfntly ha a tenant. that it is my responsibility to notify the occupant of the
r-quiremcnts hich mku be met prior to issuance ofa certificate of 0c
Z
Signature of Applicant Date
(
n
All roof coverings to be Class 'j¢" or better
Owner
orauthoriredagent ,c