00040122CITY OF CUPERTINO
1 BUILDING DIVISION
" BUILDING ADDRESS:
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PERMIT NO.
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SANITARY NO. - APPLICATION STUBBMITTTI
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LICENSED CONTRACTORS DECLARATION
' hereby affirm that I ton irunder of Chapter 9 (cnmme ng
Job Description
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ARCHITECTS DECLARATION
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I understand my plans dull W Mand as public records
d r o Licensed Professional
OWNER -BUILDER DECLARATION
G 'o 1 hereby a inn Nei 1 am exempt from Ne Contractor's License Law for the
O following rc n. (Section TO3L5, Business end Prnfmianv Cade: Any city w rnunq
which rei mrsa a permit to construct, alter, improve, demolish, or «per any surctime
prior to in issuance. also inquires the applicant for such permit to file a signed statement
Mat he is licensed Pursuant to Ne provisions of Ne Contractors Licene Law (Chapter 9
a (commencing wish Section 7") or Division 3 of the Business and Professions Code)or
Nn he is exempt therefrom sod this, but; for she alleged exemption. Any violation of
'Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of -
nes mom than five handled dollars ($500).
1, as owner of de progeny, m my employees wish wages m Nair vole compeneedoa,
will dothe work, and Ne structure is not intendndorofiered fmsele(Sec. 7044, Business
t 'and Professions Code: The Cantiawors License Lew does nes apply to an .,.& '
properly who builds or improves themon, and who does such work himself m through. „
his own employees; Provided that sucti improvements me nm intended or offered for
sale. If, however, the building or improvement is sold within one year of completion, she
owner Wilder will have the burden of proving Nat W did net build or improve for Mr -
pose of sale.). '
❑ I. in owner of Ne property, am exclusively contracting wish liunsed contractors to
consruct the project (Sec. 9014, Business and Profession. Code:) The Contractor'. W.
cense Lew does not apply to an owner ofpropemy who builds or improves thereon, and „
who commctsfarsuch prjecu with a contractors) licensed pursuant to she Commuctor's
Liuna Law.
❑ l nm exemprrSec,i .B& P C for Nis reasons ,
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'>nKERSCOAPENIATION DECLARATION
1 hereby eMo. uoder,maty of perjury one of the following declwations:
. ❑ I have and will maintain a Certificate ofComento self-insum for Workers Compen.
cation, as Provided for by Section 3900 of the Labor Code, for the performanu of the
work for which this permit is issued.
❑ 1 have and will maintain Warkei s Compensation Insurance. as "oriented! by Section
3900of Ne Labor Cade, for Ne perf rmwnce ofthe work for which this permit I. W.M.
MY Worker'sConn an Insv <arria and Policy a 4Z
Genesee [p" Policy No:
CERTIFICATE OF EXEMPTION FRO RXERS'
COMPENSATION INSURANCE
(This swdnn sad nor W completed if the permit is picture hundred dollen ($100)
or less.)
• I unify that in she performance of Mesouls for which this permit is issued, l shall
not employ any person in any manner so as it become .subject to the Workers' Compen-
sation Laws of California. Dam
Applicant
.. NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject io Ne Workers Compensation provisions of the Labor Cade. you must
forthwith comply with such provisions on this permit shall W domed mooted. -
CONSTRUCTION LENDING AGENCY
c 0 I hereby alfmnn that them is a construction lending agency far he perfwmaneeof
Z Ne work for which this permit is issued (Sec. 3099, Co, C.)
s.y Lender's Name
(X > Lenders Address
Lra QI cenify Nat I have read this application and state that the above information 1.
Gs const. I agree to comply with all city and county ordinances and sure laws relating to
buildingconsruction, and hereby authorise mpesentatives of Nis city to enterupon Ne. ,
C.i above-memiunnd property for inspsction purposes.
(We) agree to save, indemnify and kap harmless Ne City of Cupertino against s
0 C.i liMolides,minodnta, costa add eapenses which tory in any way accme egmml said City `
Loi in conequeuce of the grammes% of this pcmh.
aFi APPLICANT UNDERSTANDS AND WILL
souaP MPLY WITH ALL NON -POINT
U � .aecu yrp3 gn n_ ., .n. •
Sq. Ft. Floor Area '
APN Number
Required Inspections
Valuation
.W—mu .1 opPetwo—monal.-
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or furore Wilding occupier store or handle hazardous material Re -roofs. •'
as defined by the Cupertino Municipal Code, Chapter 9.12, aril the Health end Safety'
Code, Section 0532(s)9 / Type Of Roof q
• Oyes 9151. .
Widths applicant of future Wilding occupant use equipment or de vices which All roofs shall be inspected prior to any roofing, material being
cmit hamindcos air ummuntinsums as defined by he Be, Artea A& Quality Mention., .installed. If a roof is installed without irst obtaining an inspection
Yes
c � I a ree to remove all new materials for inspection. Applicant
❑
I have read the hazardousmlv
materials iremerN under Chaper 6.95 of she Call un erstands and will,eomply with all non point source regulations.
forma HeAM & Safety Code, Sections 25505, 25533 and 25534.1 undantaM Net 'the C "
building does nocm cu ��Ony haveaenant, Wtit is my tod.conificksmylhe ucupani
of the i J at be m miss ace of a Ceatifcae of OccupencY. r defeV - r
Signawre,of A Leant Date
41
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All roof coverings to be Class `B" or better
OFFICE