08030117CITY OF CUPERTINO
BUILDING DIVISION PERART cc
BUILDING pDRESS_ PERMrr NO.
G1�10 VAI AVE TBD - TO BE DETERMINED 08030117
OWNER'S NAME: PERMIT ISSUE DAIS
CHIA-
NO. CONTROL NO.
ARCHITECT/ENGTNEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm teat I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
License Class Lic. tl
Date Contractor
ARCHITECPS DECLARATION
I understand my plans shall he used as public records
Licensed Professional
OWNER-BUMDER DECLARATION
1 hereby affirm that 1 am exempt frum the Contractor's License Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or county
which requires a permit to construct, sites, 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 pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Profmions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant for a penult 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,
will do the work and the structure is not intended or offered for sale (Sec. 7044. Business
and Professions Code: The Contractor's License law does not apply to an owner of
property who builds or improves thereon, and who don such work himself or through his
own employees, provided that swb 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
I
wct the pmjea (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 contracus for such projects with a contraclor(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B & P C for this rcawnD
/ a ?� ,c 0
Owner / Date
RKER'
I hereby aIDtm under rally of perjury one of the following declarations
❑ I hsve and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sadon, 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 mainain 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 Workers Compensation Insurance carrier and Policy number are:
Carrier.
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if cite permit is for oar hundred dollars ($100)
or less.)
I certify that In the performance of the work for which this permit is issued. 1 shall not
employ any person in any
Exemption, you should
become subject to the Compensation 0mvisions of the Labor Code, you rust
forthwith comply with such provisions or this it shall be deemed revoked.
CONS7RUCTION LENDING AGENCY
I hereby afrrrm that there is a eonsuvctinn lending agency for the performance of
Lite work for which this permit Is issued (Sec. 3097, Civ. C.)
(.enders 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 representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) ague to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgmers, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDER ANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REG TI S.
Signature o pli Contractor f/ Date
HAZARDOUS'MATERIALS DISCLOSURE
Will the �apphcant or far ding occupant store or handle hrmnicus material
as defined by the Cupertino M icipal Code, Chapter 9.1Z and the Health and Safety
Code, Section 25532(a)7
❑ Yes yNo
Will the applicant oe future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arm Air Quality Management
District]
❑ Yes No
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Cork:, Sections Z5505, 25533 and 25534.1 understand thin tithe building
does not currently have a tenant; it is my responsibility to notify the occupant of the
requirements which mtr§t be m or_ a Certificate of Occupancy.
Job Description
DEMO 1-STORY & DETCH'D GARAGE
Sq. Ft. Floor Area $10 0 0 Valuation
36205026.W N
Required Inspections
Issued by:
of Roof
Date
Type
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
Owner or
Date
All roof coverings to be Class'n" or better