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07050164 CITY OF CUPERTINO �. BUILDING DIVISION PERMIT PERMIT NO. BUILQII�cr4ff'S�OHNSON AVE K DESIGIS S 07050164 l U�j l PERMIT ISSUE DATE ER'S NAME: 05/17/2007 IICKERING, DON & LINDA 3480 INVESTMENT BLVD SANITARY NO. CONTROL NO. PHONE: BUILDING PERMIT INFO ARCHPIECT/ENGINEER: RETROFIT' LIVING ROOM WINDOW BLDG ELECT PLUMB MEC14 spa LICENSED CONTRACTOR'S DECLARATION ^T^r ,.,r,_, _.1ah.Description 11 V P I hereby affirm that I am licensed under provisions of Chapter 9(commencing 3UU with Section 70(10)of Division 3 of Ume Business and Professions Code,and my license is n y in full force and effecL t ? License Class 8 Contractor ON j < I understand my plans shall be used as public records u ti Licensed Professional 0< OWNER-BUILDER DECLARATION 1 hereby affirm that I am exempt from the Contractor's License Law for the p Cr,� following reason.(Section 7031.5,Business and Profcsxittns Code:Any city or county r which requires a permit to construct.alter.improve,demolish,or repair any structure Valuation N prior m its issuance,also requires the applicant for such permit to file a signed statement sq.Ft.Floor Area -?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 r x- (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or i r3 Any violation of OCCU anC Type that he is exempt therefrom and the basis for the alleged exemption. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number p y yp not more than five hundred dollars(5500). ❑I,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 Conuactors 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,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- cense 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. B&P C for this reason ❑1 am exempt under Sec. Date -r WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for WoftesCompen- 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•. ?> �/HI�TuS. Policy No.: •S'���D�'�O( CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars(EI00) or less.) 1 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 Workcrs'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 2 forthwith comply with such provisions or this permit shall be deemed revoked. Z CONSTRUCTION LENDING AGENCY F.,.�. I hereby affirm that there is a construction lending agency for the performance of CY> the work for which this permit is issued(Sec.3097,Civ.C.) W ALender's Name .ate z Lender's Address V z I certify that I have read this application and state that the above information is U.� 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. ✓" P. (We)agree to save,indemnify and keep harmless the City of Cupertino against r� CA liabilities,judgments•costs and expenses which may in any way accrue against said City U Z in consequence o[the granting of this permit. Date �+ APPLICANT Ul, ERSTA S AND WILL COMPLY WITH ALL NON-POINT Issued by. SOURC A ONS J Re-roofs w S.A.of Applicant/Contractor Date T e of Roof HAZARDOUS MATERIALS DISCLOSURE YP Will the applicant or future building occupant store or handle hazardous material +efrned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Scct(on25532(a)7 All roofs shall be inspected prior to any roofing material being installed. ❑Yes UK. 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 materials for inspection. District? ❑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 Occup t of the Date require mcntc w must Oct prior to issuance of a Certificate of Occ Signature of Applicant i All roof coverings to be Class"B"or better mer or authorized agent Date