08100088CITY OF CUPERTINO
BUILDING DIVISION PERN T
BUILDING ADDRESS:
PERMIT NO.
10679 MINET
TBD — rrE D
OWNER'S NAME:
PERMIT ISSU DAZE .
PHON :
A O. CONTROL NO.
ARCHITECTIENGLNEER:
BUILDING PERMrrINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby I licensed under Chapter 9 (commencing
Job Description
affirm that am provisions of
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and effect
DEMO EXT H S E (10 7 8 S Q )
License Class Lie. N
Date Contractor
ARCHrrECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 70313, Business and Professions Code: Any city or county
which requires a permit to construct, alcr, improve, demolLsh, or repair any structure
-
prior to is issuance, also requires the applicant for such permit to file a signed statement
that be is licensed pursuant to the provisions of the Conuactor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(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
7 5 0 0
Section 7031.5 by airy applicant for a permit subjects the applicant to a civil penalty of
dollars
APN Number
Occupancy
P Y Type
trot more than five hundred (S500).
37532039.00
❑ 1, as owner or the property. or my employees with wages as their sole compensation.
Required Inspections
will 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 employems, provided that such improvements are not intend af 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.).
❑ L ss owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044. Business and Professions Cede:) The Cenuames Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contiactor(s) licensed pursuant to the Contractors
License Law.
❑ I am acre
1 hereby affirm under penalty of perjury uric 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.
❑ 1 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 Workers Compensation Insurance carrier and Policy number are:
-
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section teed sot be completed if the permit is for one hundred dollars (E100)
_
or less.)
1 certify that in the performance of the work far which this permit is issued, I shall not
employ any person in
of Exempt on, you should
become subject to the Wo. Compensition provisions of the Labor Coda you must
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.)
L ander's Name
Lenders Address
'
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 state laws relating to
building construction. and hereby authorim representatives of this city to enter upon the
above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
'
liabilities, judgments, costs and expenses which may in any way stave against said City
in consequence of the granting of this permit.��
APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON -POINT
Issued by: Date �d
SOURCE REGULATIONS. /
ATFctAI S 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 shall be inspected to any roofing material being installed.
❑Yes ZfNa
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or ruturc building occupant use equipment sir devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? -q
❑ Yes allo
1 have marl the harardoui materials requiremems under Chapter 6.95 of the calirer-
nisi Health &
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