07060101 CITY OF CUPERTINO
BUILDING DIVISION PERMIT RZW :nJA .tt.:1l1l�T
EUIL I R PERMIT NO.
M �LCAZAR AVE TBD To BE DETERMINED 07060101
R'S NAME: PERMIT ISSUE DATE
K. Y. HO 09/05/2007
PHONE: SANITARY NO. CONTROL NO.
tARCHITEGT/ENGINEER: I BUILDING PERMIT
HOUSE D-MO BLDG ELECT PLUMB MECH
•
O a LICENSED CONTRACTOR'S DECLARATION
L is I hereby afri m that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is
ti in full force and effect.
z License Class ic.ff
w Date Contractor
a ARCHITECTS DECLARATION
m< I understand my plans shall be used as public records
o,V
O Licensed Professional
H OWNER-BUILDER DECLARATION
j a 1 hereby affirm that I am exempt from the Contractor's License Law for the
p O following reason.(Section 703 1.5,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
x a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 �q.Ft. Floor Area Valuation
% (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
3- that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
not more than five hundred dollars(5500). P Y
❑I,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(See.7144,Business
and Professions Code:The Contractor's License Law does not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements arc not intended or offered for sate.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.).
�3'1,as owner of the property,am exclusively contracting with licensed contractors to
tonswct the project(Sec.7044.Business and Professions Code:)The Comtraetoes Li-
cense law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a tontractor(s)licensed pursuant to the Contractor's
License Law.
r am exempt under Sec. B&P C fPP\r/����/ton
W Dale
ORk 'S CO SATION DECLARATION
I hereby trm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate 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.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the performance of the work for which this permit is issued.
My Workees Compensation Insurance carrier and Policy number ate:
Cartier. Policy No."
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars(S 100)
or less.)
I certify that in the performance of the Bork for which this permit is issued,I shall no
employ any person in any manner so F become subject to the Workers'Cgm!7=*om
Laws of California.D p // ��
Applianl
NOTICE TO APP CA :If,after making this Ceni(icatc of Excm{�tidn,yy6r should
become subject the Worker's Compensation provisions of the Labor Code you must
Z foMwith comp ith such provisions or this permit shall be deemed tevaked.
Z CONSTRUCTION LENDING AGENCY Cn
E-r — I hereby affirm that there is a construction lending agency for the performance of
C.' ✓> the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Nam^
Z Lender's Address
U C) 1 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 authoriTe representatives of this city to enter upon the
J above-mentioned property for inspection purposes-
' a (We)agree to save,indemnify and keep harmless the City of Cupertino against
i
*-+ vliabilities,judgments,costs and expenses which may to any way accrue against said City
Q)Z in consequence of the granting of this permit. 7
r r APPLICANT UNDERSTANDS WILL COMPLY WITH A NON-POINT Issued by: Date f ��
SOURCE REG ONS. ���/O� ;Q
Re-roofs
Signature fApplirant/Conractor t /Dale
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
k!!the applicant or future building occupant store or handle hazardous material
'efined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
e.S]Yes []No 25532(a)?
❑ All roofs ;hall be inspected prior to any roofing material being installed.
Yes
Will the applicant or future building occupant use equipment or devices which If a roof i;installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ❑No
[have read the hazardous materials requirements under Chapter6.95 of dw Cal ifor-
nia Heald&Safety Code,Sections 25505,25533 and 25534.I understand That if doe building
does not currently have nant,that it is my responsibility to notify the occupant of the
require ts which m be metlprior to issuance of a Ccnificateeoof Occu Signature of Applicant Date
• l 1�'" at All roof coverings to be Class "B" or better
O er or authorized agent � Date-