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CITY OF CUPERTINO�
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BUILDING DIVISION PERMIT
BUITftTSESkEVENS CREEK BLVD
TBD - TO .BE DETERMINED
PERMIT NO.
08090051
OWNER'S NAME:
PMUM ISSUE DATE
CITY OF CUPERTINO
09/11/2008
PHONE:
SANITARY NO. CONTROL NO.
ARCIirTECrfENGTNEER:
BUILDING PERMIIINm
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Chapter 9
Job Description
p -on
I hereby affirm that I am liouacd under provisions of (commencing
with Smdon 70W) of Division 3 of the Business and Profasorucode. and my license u
DEMO POOL AND POOL RE STROOM
in full force and effect.
License Class Lk 0
Date Comma"
ARCHITECTS DECLARATION
1 undersand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Coda Any city or county
which requites a permit to construct. alter, improve, demolish, or repair any wuctme
prior to its ismanm also requires the applicant for such permit to file a signed statemerm
that he is licensed to the of the Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
$ 1 0 0
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that be is exempt therefrom and the bads for the "cued exemption. Any violation or
e,�Number
32629022,V tf
OCCU anC
P y Type
Section 7031.5 by any appllcam for a permit subjects the applicant to a civil penalty of
nut mom thin five hundred dollars (:sou).
❑ L as owner of the property. or my employees with wages as their sole compensation,
Requited Inspections
will do the work, and site smucairc is not intended or offered for sale (See 7044, Business
and Professions Cole The Contractors I scene Law does not apply to an owner of
property who builds or improves thasoy and who does such work himself or through his
awn employees, provided that such improvements are no intended or offered for sale 11.
however. the building or Improvement is sold within one year of completion. the owner -
builder will have the burden of proving that in did not build or improve for purpose of
.
sale.
'.
I, u owner of the property. am exeludvely contracting with Hennaed contactors to
construct the pmj= (Sec 7044. Business and Professions Code:) The Contractors u
cease Law does not apply to an owner of property who builds or improve thereon. and,
'
who contracts for such projects with a contractor(s) licensed pursuant to the Contactors
License Law.
❑ I am ex t under Sec , B & P C q this reason
Owner Dale
w6RKER,s'EOAPFENSA7lqKDECLARATION
1 hereby affirm under penalty or perjury one of the rollowint declarations:
❑ I have and will maintain a CratlBeale of Consent to self -Insure for Worker's Compen-
.
sadon, as provided for byscedon 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compe nailon Insurance, as required by Section
3700 of the Labor Code, for the performance of the wale for wbkh this permit is issued.
My Worker's Compensation Insurance terrier and Policy number am:
Carrier-. Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not be completed if the permit is for one hundred dollars (310(l)
or less.)
I certify that in the performance of the work for which this permit is Luued. I shall not
employ any person in any m;prycr so u b hecoroc subject to the Worfers' Comperradon
.
Lawn of Calif (a. Duo A//�1AT -
Apputant t �tA-+ftae
NOTICE TO APPLICANT: If, alley making this Cenifinre of Exemption, you should
become subject to the Wortrrs Compensation provisions of the Low Cock, you must
forthwith comply with such provisions or this peunit shall be deemed revoked -
CONSTRUCTION LENDING AGENCY
1 hereby affirm that their is a consuwdon lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Civ. C)
Lender's Name
Lenders Address
.
l certify that I have read this application and state that the above infomation is
correct. I agree to comply with all city and county Ordinances and stale Taws n:Lring.to
building construction. and hereby audxdm 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 CUPMIh o apJast
IiabiliLim Judgments., coos and expresses which may in any way accrue against said City
in cosequence of the granting of this permit.
APPt ICANI UNDt7tSTA SAND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S CE REGULATIONS
Re -roofs
Type of Roof
alahes
Signature olApplkant/Con Bare
HAZARDOUS MA DISCLOSURE
WIH the applicant or future building occupant sore or handle hazardous material
as defined by the Cupertino Municipal Cott_. Chapter 9.12. and the Healtb and Safety
Code. Section 25532(a)7
p Yes pry.
All roofs shall be inspected nor to an roofing material being installed.
P P Y g g
If a roof is installed without first obtaining an inspection, I agree to remove
WIU the applicant or future building occupant use equipment or devices which
emit hrzardous air conaminana as da0rted by the Bay Area Air Quality Maagemem
all new materials for inspection.
Drsuxt0
Yes �No
l have mad the harmd xu mWdala mWimmcros Order amptcr&95 of the Cslifor-
Na Health & SafayCodc, Sections 25M5, 25533 and Z5534- I wderuatd that H sire building
does not currently have a tenant, that it is my responsibility to notify the occupant of the
? • u which must be tt pr;« b issoanen Ora Certificate ofa_upa,ty.
Signature of Applicant Date
-ct aa�'"a'wa�.�tl - 9h9 �oS/
Al] roof coverings to be Class "�y. or better
g FI
Own or authorized digress Dare