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081002030� z. ^" U wG0. 7 e UC E.. C .. G U� CITY OF CUPERTINO BUILDING DIVISION PERNUT Fx-,�� �© ' BUILDING ADDRESS: PERMIT NO. 22831 MERCEDES RD TBD — TO BE DETERMINED nsinn203 OWNER'S NAME: PERMIT ISSUE DAIS CONTROL NO. ARCHITEcT1ENGINEER: BURDBJG PERMIT INFO '^ BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECIARATTON - -- Job Description ti��ffil-hartira_I - commcaein - with Secof Division m��cm KITCHN & FAM RM RMDL, 216SQ;NO—REROOF OR STRUCTRL License (lass Lfc. car D. o Contractor *DOWLING BLDRS, INC. PD FOR BUS LIC 10 / 3 0 / 8 $110 -AACHITECT'S DECLARATION J- 1 understand my plans shall be used as public records Law d Professional OWNER -BUILDER DECLARATION I hereby affirm Thu 1 am exempt from the Contractor's License Law for the following reason. (Section 7031-3, Business and ProGtsaions Code: Any city or county which require a permit to construc,4 alter, improve, demolish, or repair any suuctum prior to its issuance, also requires the applicant for such permit to file a signed statement that he is licensed pursuant to the provisions of the Conractor's U=ruc Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7000) of Division 3 of the Business and Pmfestlons Code) or 9 5 0 0 0 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by arty applicant for a permit subjects the applicant to a civil penalty of not more than five hundred doflua (S500). 34222091.00 ❑ L as owner of the property, or my employees with wages as their sole eompengdon, Required Inspections will do the work and the structure is not hrrertded or offered for sale (Sere. 7044, Business and Professions Code The Contactors License taw dos not apply to an oww of property who builds or improves thereon, and who does such work himself or through his Own employers, provided that such improvements ate 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.). ❑ L as owner of the properly, am exclusively contracting with license d c0fluactors to construct the project (Sec 7044. Business and Professions Code:) The Conbactors Li - =rise taw does Dot apply to an owner of property who builds or improver thereon, and . who contracts for such projects with a contractor(s) licensed pursuant to the Contactors License Law. . ❑ I am exempt under Sec . B & P C for this reason Owner Date WORKERS COMPENSATION DECLARATION I hereby affirm under penalty of perjury One of the following declarations ❑ I have and will maintain a Certificate or Consent to self -insure far Workers Compen- sation, as provided for by Section 3700 of the Labor Code, for the pieformanc a of the work for which this permit is issued. ❑ 1 have and will maintain Workers Comprnsaton Insurance, as required by Section 3700 or the Labor Code, for the performance or the work for which this permit is issued My Workers Compensation Insurance artier and Policy number am: carrier.. s No.: vi CERTIFICATE OF OMMPTION FROM RKERS' COMPENSATION INSURANCE (This section need not be completed tribe permit Is for one hundred dollars ($I00) or less) I certify that in the performance of the work for which this permit is Issued, I shall Dot employ any person in any manner so as to become subject to the Work=' Compensation Laws of California. Date App6wrl NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions of the Labor Code. 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 or ' the work for which this permit is issued (Sec. 3097. Civ, C.) Lenders Name LeMers Address I certify out I have read this application and suite that the above information is " correct 1 agree to comply with all city and county ordinances and state laws relating to A building construction, and hereby authorize represer La&a of this City to enter upon the above -mentioned properly for inspection purposes. (Wc) agree to save, indemnify and keep harmless the City of Cupertino sgainst j liabilites,judgments, costs and expenses which may in any way accrue against said City r in consequen= of the grantL ng of this rmi " APPLICANT UNDERSTA ND ILL COMPLY WITH ALL NON -POI �, Issued by: Date SOURCE L-KTI v !/ Re -roofs Signet Appli Con mr Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof 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. Section25532(a)? ❑Yes All roofs shall be inspected prior to any roofing material being installed. )PLNo If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment of devices which emit hazadous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. DLstrict7 ❑ Yes �No 1 have read the hamrdousrmaterials requirements under Chapter 6.95 of thc Califor- nia Health & Safety Code, Sections 25505.25533 and 25534.1 understand that If the building does riot curenty base a trnan y responsibility to notify the occupant Of the requiremen which mast t car to4ssuincc era cenir"„" or t7ccvparnry. Signature of Applicant Date a All roof coverings to be Class '%.'` or better iyc Date . Owrherorau age _