08010163L
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
' iVTRAET0R INFO
sult�l�tr�Ap(�RE0NALD
P8010163
WAY NOKOBATA
TAMOTSU AND MEGUMI
:
SANITARY NO. CONTROL NO.
ARCHI'FECT/ENGINEER:
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BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Descripption
1 hacby affirm that I am licensed under provisions of Chapter 9 (Commrnci"
with Section 7000) of Division 3 of the Business and Professions Code, and my licenso i
TCHN (14 0 SQ) , BTHRM (4 0 SQ) , BDRM (14 4) & FAMRM (18 0) REMOD
in full force and effect
License Class Lic. ft
CHN (14 0 SQ) , BTHRM (4 0 SQ) , BDRM (14 4) &FAMRM (18 0) REMODE
Dam conuacuir
ARCHITECTS DECLARATION
HN (14 0 SQ) , BTHRM (4 0 SQ) , BDRM (14 4) &FAMRM (18 0) REMODEL
1 undersiand my plans shall be used is public records
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Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt fmm the Contractor's License Law for the
following reason. (Soction 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, 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 to the of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
pursuant provisions
(commencing Section 7000) of Division 3 of the Business and Professions Code) or
$ 8 0 0 0 0
with
that be is exempt therefrom and the buts for the alleged exemption. Any violation of
5 618 0 0 6 0 �tPN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty o(,
not more than five hundred dollars (SS00).
.
❑ L as owner of the property. or my employees with wages as their sole compensation,
Required Inspections
will do the wort, and the structure is not intended or offered for sak (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 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
le.).
. as owner of the property. am exclusively contracting with licensed comtractors to
. construct the project (Sec- 7044. Business and Professions Code:) The Contractor's 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 Contractor's
License Law.
❑ 1 an t-vrrde See , B & P for this reason
Dam 1
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations
❑ I have and will maintain a CertiLate of Consent to self -insure for Worker's Compen-
sation, 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 Worker's Compensation insura cc, 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 carrier and Policy number are:
.
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectionneed not lic completed tribe permit Is for one hundred dollars (5100)
or less)
1 certify Chet in the performance of the work for which this permit is issued, I shall not
employ any person in an�rtanncr so u m become subject i� the Wo ' Com tion
Laws of Cali f�c 3 � 1
Appi
NOTICE TO APPLICANT: If, after making this Certificate of Esc Goer, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hernby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec, 3097, Civ, C.)
Lender's Name
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Lender's Address
I certify that I have read this application and state that the above information is
'
correct 1 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) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgmenta, cons and expenses which may in any way accrue against said City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALJ, NON -POINT
Issued by:
of Roof-�U"�-�
zo
Signature of Applieant/Contractor Dam
HAZARDOUS MATERIALS DISCLOSURE
WIi the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino M , 'pal Code, Chapter 9.12. and the Health and Safety
Code , Station 25532(a)7
All roofs shall be inspected prior to any roofing. material being installed.
❑ Yes
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 fined by the Bay Area Air Quality Management
all new materials for inspection.
DisuicO
❑Yes ❑N
I have read the hazardous materials requirements under Chapter6.95 of the Califor-
nia Health & Safely Code, Sections 25505, 25533 and 25534.1 understand that if the building
does not currently have a icnant, drat It is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a CJwatc of cvpan .
Signature of Applicant Date
All roof coverings to be Class " B" or better
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Owner Dam '
or authorized agent