07080217BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHITECTIENGINEER:
Z LICENSED C'ONTRACTOR'S DECLARATION
0
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
U with Section 7000) o Division 3 of the Business and Professions Code, and my license is
in full force and eft .
? License Qass Lk. q�A
p Date i 7. -n:q -Contractor
ARCHITECTS DELLA ON
-' I understand my plans shall be used as public records
y Licensed Pndcssional
OWNER -BUILDER DECLARATION
g 1 hereby affirm that'I am exempt from the Contractor's License Law for the
o following reason. (Section 7031.5, Business and Professions Code: Any city or county
114 which requires a permit to construct, alter. improve, demolish, at repair any structure
y prior to its issuance, also requires the applicant for such permit to file a signed statement
0 that be is licensed pursuant to the provisions of the Contractor's license Law (Chapter 9
e (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
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
not more than five hundred dollars (S500).
0 I, as owner of the property, or my employees with wages as their sole compensation,
wig do The work, and the structure is not intended or offered for sale (Sec. 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 wort 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.).
0 L as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Code:) The Contractor's Li -
cause 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 Contractor's
License Law.
Ej I am exempt under Sec , B & P C for this reason
PERMIT NO.
A
SURFARFZT2 U U CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
REVISE GARAGE LOFT STORAGE AND FAMILY ROOM
CEILING
RAFTERS-ORIG PERMIT 407050202 NO NEW
PERMIT.
Sq. Ft. Floor Area Valuation
APN Number Occupancy Type
32641080.00
Required Inspections
Date- ---
WORKERS COMPENSATION DECLARATION
1 bemby affirm under penalty of perjury one of the following declaratioru:
1 have and will maintain a Certificate of Consent to self -insure for Worker'sCompen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the perform== of the wort for which this permit is issued.
ar
My Wor C mpe a .on Insuran carrier and Policy num
Carrier.
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 work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
z forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued (Sec. 3097, Civ. C.)
0 Lender's Name
z Lender's Address
Q 1 certify that 1 have read this application and state that time above information is
'-" corecl. I agree to comply with all city and county ordinances and stare laws relating to
Vbuilding construction, and hereby authorize representatives of this city To enter upon the
U above-mentioned property for inspection purposes
(We) agree to save, indemnify and keep less rhe City of Cupertino against
� liabilities, judgments, c ss and which In any way accnrc against said City
inconsequence fthe
Signature at Applicant/Con Dare
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as damned by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(a)?
❑ Yes o
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Yes
I have read the hazartlwrs materials immems under Chapter 6.95 of the Califor-
nia Health & Safc Codc 25505. 3 and 25534.1 understand that if the building
does
ance of a Certificate of Occupancy.
Owner or authorized agent Date
Issued by:
Re -roofs
Type of Roof
Date- Zy�
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant
Date
All roof coverings to be Class "B" or better