08020151CITY OF CUPERTINO T {7
BUILDING DIVISION .PERMIT
BUILgIITGeA ESEINDY PL
TBD - TO BE DETERMINED
U 8 U U 151
SANITARY NO. CONTROL NO.
ARCHrrECTIENGINEER:
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 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
ADD 423 ' BEDROOM , 6 5 ' PORCH, 6 0 0 ' DECK (FOYER
�renseGand erkm. Lac
EXTENSION) -REMODEL 1 360 ' BEDROOM, KITCHEN, FAMILY
Date Contractor
ARCHri'EC 'S DECLARATION
,
RM `
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, demolish, or repair any structure
prior to its issuance, else requires the applicant for such permit to file a signed atatrmem
Contractors LiccrLa ILw 9
Sq. Ft. Floor Area Valuation
that he is licensed pursuant to the provisions of the (Caaptcr
2 5 O O O O
(commencing with Section 7000) of Division 3 of the B usinrss and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
356240 05 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 (SS00).
[] 1, as 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 (Sex. 7044, Business
and Professions Code- The Contractors 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 axe 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 nrot build or improve for purpose of
sale.).
30 L as owner of the property. am exclusively contracting with licensed contractors to
co the project (Sec. 7044, Business and Professions Code:) The Coouaetors Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
,
such 'contractors) licensed pursuant t0 the Contractors
who co9WOREKE�:�SATION
License[] I am B & P 7C f town
Owncr Date 7 I Oi 5
DECLARATION
I hereby a1Tum ern salty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -Insure for Workers Compen-
sation, as 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 Insurance, 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 axe:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(this section need not be completed If the permit is foronc hundred dollars (S 100)
or less)
1 certify that in the perfo ce or a wol for which this permit is Wood, I shall not
employ any
Applicant
NOTICE TO making this Ceriftcam of Exemption, you should
become subjm to the Wor s Compens idon provisions of the Labor Codc, you must
r forthwith comply with provisions or this p=niL shall be deemed revoked.
" CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
0 the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lenders Address
j 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 stale laws relating to
building consruction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purposes
4 (We) agree to save, indemnify and keep harmless the City of Cupertino against
ry liabilities, judgments, toss and expenses which may in any way acmie against said City
V in consequence of the granting of this iL
APPLICANT UNDERSTAND A I OMPLY WITH ALL NON POINT
Issued Date
SOURCE REGULATIONS.
31 0
Re -roofs
Type of Roof
Signature of Applicant/Contractor I Ditc
HAZARDOUS MA ALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
'
as damned by the Cuperino Municipal Code, Chapter 9.1Z and the Health and Safety
Code, Section25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Dyes yNo
If a roof.is installed without first obtaining an inspection, I agree to remove
WIO the applicant or future building occupant use equipment or devices which
emit hazardous air comaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
El Yes
1 have read tie hazardruv materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 533 and 25534.1 understand ihat If the building
does not currently have a Lenin th y 'bility w notify the occupant car the
requiremenswhich must t oraCard"toofOcca ry.
Signature of Applicant Date
f 60 `'
All roof coverings to be Class'4' or better
OwneJ nr a,�hnrn .Pent to