06030135 CITY OF CUPERTINO
BUILDING DIVISION PERMIT C� i' R� gOR IQRM�iTI(IlY'
BUILDING ADDRESS: PERMIT NO.
977 S TANTAU AV TBD - TD BE DETERMINED 06030135
PERMIT ISSUE DATE
01"NER'S NAME:
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
10p LICENSED CONTRACTOR'S DECLARATION Job Description
u1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADD I T I C N 550 ' -LIVING RM/DINING RM
I a a in full force and effect.
;=)? License ClassLie.x 11/07/06 - PERMIT APPL EXTENDED TILL 3/23/07 . NO
h w Date Contractor
ARCHITECTS DECLARATION MORE EXTENSIONS.
i ce< I understand my plans shall be used as public records
)WU
W t-- Licensed Professional
y OWNER-BUILDER DECLARATION
I 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 yy prior to its issuance,also requires the applicant for such permit to file a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area
F=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $117903
y that he is exempt therefrom and the basis for the alleged exemption.Any violation of �pN
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 37538054 . UO Number Occupancy Type
not more than five hundred dollars(5500).
❑1,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(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q p
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-
z
have the burden of proving that he did not build or improve for purpose of
ner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with ac tractor )licensed pursuant to the Contractor's
License Law.
❑I am exempt under
ECLARATIONIherebyaffirmnaltyof rjury one of the followingdeclarations:
❑I have and will mairtificate 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 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
of Exemption,ya should
become subject to the Wor 's Com nsa' provisions of the Labor Code,you must
,J Q forthwith comply with INSTRUCT10N
provisions oroh permit shall be deemed revoked.
z'" LENDING AGENCY
(-r Cn 1 hereby affirm that there is a construction lending agency for the performance of
(x> the work for which this permit is issued(Sec.3097,Civ.C.)
Wei.A Lender's Name
z Lender's Address
V 0 1 certify that I have read this application and state that the above information is
correct.1 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.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
,may liabilities,judgments,costs and expenses w'h may in any way accrue against said City
U Z in consequence of the grantin f 's per t Date
►-� APPLICANT UNDERST ND L COMPLY WITH ALL NON-POINT Issued b,':
SOURCE
Will the applie t or future ilding occupant store or handle hayardous material
as defined by the, vino Municipal Code.Chapter 9.12,and the Health and Safety
ndc,Section 25532(a)?
❑Yes All roof: shall be inspected prior to any roofing material being installed.
tr�
Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes o
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sec' 25505, 33 and 25534.1 understand thatif the building
docs not currently have a a tit' y responsibility to notify the occupant of the
requirements which m r uance of a Ccruftcatc Q Oce _y. Signatur,s of Applicant Date
7J °oto All roof coverings to be Class "B"or better
Owner or authorized a t