07040008 CITY OF CUPERTINO C� 'I'ktATC�RIC� M �'I1�•
BUILDING DIVISION PERMIT PERMIT NO.
BUILJI�6( Wl fil�ULBERTSON DR TBD — TO BE DETERMINED 07040008
(J �j(� l PERMIT ISSUE DATE
OWNER'S NAME: 05/22/2007
DONGLIN MI SANITARY NO. CONTROL NO.
NE:
BUILDING PERMIT INFO
ARCHITECT/ENGINEER: BLDG ELECTPLUMB MECH
ed Z LICENSED CONTRACTOR'S DECLARATION Job Description
VI hereby affirm that I am licensed under provisions of Chapter 9(commencing HOUSE DEMO
Z U with Section 7000)of Division 3 of the Business and Professions Code,and m license is
>> in full force and effect.
v.2 2 License Class fie'
Date
Contractor
ARCHITECTS DECLARATION
;1" 1 understand my plans shall be used as public records
)yU
a N Licensed Professional
•o a OWNER-BUILDER DECLARATION
aI hereby affirm that 1 am exempt from the Contractors License Law for the
p O following reason.(Section 7031.5•Business and Professions Code:Any city or county
w� which requires a Permit to construct.alter.improve,demolish,or repair any structure Valuation
o"ui prior to its issuance,also requires the applicant for such permit to rile a signed statement S Fi.Floor Area $3500
=Z a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 9
t=G (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of p Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 7 5 3 4 0 3 7."17
not more than five hundred dollars($500).
❑1,as owner of 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 Contractor's 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.)1
!aa owner of the property,am exclusively contracting with licensed contractors to
ccoonstmct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
:r Law docs 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. gC or this anon
❑I am el a p(tt under
gSecin:
�A710N
L
Own er J 1C. 1 fakWORKE MECLARATK)
I herebyaffirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate 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.
❑1 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 Worker's Compensation Insurance carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it the permit is for one hundred dollars(S 100)
or less.)
I certify that in the performance of the work f r whit this' rmit is issued.1 shall not
employ any person in any manner so as to Ftee rttu totOte Workcrs'Compensation
Laws of Califomia.D Jt01
Applicant
NOTICE TO APPLICA :I,after makin this Certificate of Exemption,you should
become subject to the Worker's ComPcnsa n provisions of the Labor Code,you most
Z forthwith comply with such provisions or this permit shall be deemed revoked.
Z" CONSTRUCTION LENDING AGENCY
Fr En 1 hereby affirm that there is a construction lending agency for the performance of
(Z r7 the work for which this permit is issued(See.3097.Civ.C.)
W Q Condo's Name
0, Lender's 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
rJ U building construction,and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
a (We)agree to save•indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City Date
U Z in consequence of the granting of this permit.
OINT Issued by:
t–. APPLICANT UNDERSTANDS AND WIL COMPLY WITH ALL NON-
SOURCE REOWLATIONS. '7I
_
Wei VI o Q2 S 1 102 Re-roofs
Signature of Apphcant/Contractfl Da1C T of Roof
HAZARDOUS MATERIALS DISCLOSURE Type
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
Cale,Section 25532(a)? r All roofs sha.l be inspected prior to any roofing material being installed.
C]Yes If a roof is installed without first obtaining an inspection,I agree to remove
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 all new mate-ials for inspection.
District? t—
❑Yes o
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 occupant of the Date
requircmcgis which must be met prior w i uancc of a Certificate of Occupancy. Signature of Applicant —
W i ar1� G�1 V-7- 6 All roof coverings to be Class"B" or better
Date
Owner or authorized agent