07050228 CITY OF CUPERTINO
BUILDING DIVISION PERMIT S Imo+ RMATIQN.
BUILDTft reV'kkNN DR TBD - TO BE DETERMINED PERMIT 07050228
ll b b PERMIT ISSUE DATE
OWNER'S NAME:
09/26/2007
SANITARY NO. CONTROL NO.
iNE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
(� 0 L__J
p p LICENSED CONTRACTOR'S DECLARATION Job Description
U
:z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is NEW 2—Sr'ORY RESIDENCE• 3802 ' GARAGE. 654 ' PORC H
t H in full force and effect
t n? License Class Lic.# 466
t uun Date Contractor
ARCHITECT-S DECLARATION
i a< I understand my plans shall be used as public records
)WU
U.y Licensed Professional
y OWNER-BUILDER DECLARATION
> 1 hereby affirm that 1 am exempt from the Contractor's License Law for the
'00 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
Z; prior to its issuance,also requires the applicant for such permit to file a signed statement .Ft.Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. $869852
2 F (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i R that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of tl Number Occupancy Type
not more than five hundred dollars(5500). 326190154.
[11,as owner of the property,or my employees with wages as thew sole compensation,
will do the work,and the structure is not intended or offered forsale(Sec.7044.Business Required Inspections
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 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.).
I,as owner of the property,am exclusively contracting with licensed contractors to
U.the project(Sec.7044,Business and Professions Code:)The Contractors U.
cense Law does 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 Contractors
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date�`^s'v'
DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure for Workcr 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 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 the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for w ich this permit is issued,1 shall not
employ any person in any manner so as to a bjec the Workcrs'Compensation
Laws of Califomia ate
Applicant
NOTICE TO APPLI a tc Ccniricatc of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
z " CONSTRUCTION LENDING AGENCY
E~.r I hereby affirm that there is a construction lending agency for the performance of
tx.� the work for which this permit is issued(Sec.3097,Civ,C.)
W Q Lender's Name
z Lender's Address
U C I certify that 1 have read this application and state that the above information is
UL 0-4 correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
ce) liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the grantin of this permit.
�^ APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL N N-POINT Issued by: Date
S n
"7 Re-roofs
Signature o ticonvactor D'le Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs;;hall be inspected prior to any roofing material being installed.
❑Yes [ 10
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?
C]Yes [ANu
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant,that it is my responsibility to notify the occu t of die
requirements
Da All roof coverings to be Class"B"or better