07090005 77
CITY OF CUPERTINO GT(j IE�RM TIQ.lY'
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
t — A
OWNER'S NAME:
__----- SobTmW1,66.2 U 7 CONTROL NO.
*7
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
'O
LICENSED CONTRACTOR'S DECLARATION lob Description
I hereby affirm Thal I am licensed under provisions of Chapter 9(commencing
U with Section 7000)of Division 3 of the Business and Professions Code,and my license is
y in fust force and effect. ATTACHED GRt1NNY UNIT 800 '
Z License Class Conti
p
Date
Contractor
w ARCHITECTS DECLARATION
� 1 understand my plans shall M1c used as public records
/ Licensed Professional
'a OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
j O following reason.(Section 7031.5,Business and Professions Code:Any city or county
F which requires a permit to construct,alter,improve,demolish,or repair any structure Valuation
prior to its issuance,also requires the applicant for such permit to file a signed statement S9 Ft. Floor Area
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
(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 o[ P,pN Number Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars($500). 36202028 . 00
O 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.).
Kas owner of the property,am exclusively contracting with licensed contractors to
nsuucl 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 is reason
Q 1 am exeunder Sec.
Owner Date
WORKER'S COMPENSATION DECLA Date
I reby affirm under penalty of perjury one of the lowing declarations:
have and will maintain a Certificate of Consent to f-insure for Workcr's Compen-
.—,on,as provided for by Section 3710 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 Codc,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
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 performance of the w rk fo which this the Tito si sued shall not
n
employ any perso • y manner
Laws of Califo ate
Applicant
NOTICE T P LICANT:If,after making this C nate of prion,you should
become subj ct to the Worker's Compensation provisions of the Labor Code, u must
Z forthwith co ply with such provisions or this permit shall be deemed rcv d
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency Cnr th ormancc of
> the work for which this permit is issued(Sec.3097,Civ.C.)
zLender's Name
Lender's Address
0 1 certify that I have read this application and state that the above information is
i--r correct.I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction,and hereby authorize representatives of this city to enter upon the
W 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 accrue against said City
Zin con nce of the granting of this permit. Date
�, APP C NT UNDERSTANDS AND COMP ITH ALL NON-POINT Issued by:
SO EGULA
- Re-roofs
gnature of Applicant/Contractor te Type of Roof
HAZARDOUS MATERIALS DISCLOS RE yp
Will the applicant or future building occupant store o andle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9 ,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
oY°5 If a roof is inst0led without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
.strict?
Q Yes UN^"
I have read the hazardous materials rcquircmcn under Chapter 6.95 of the Califor-
niaHcalth WietyCode,Sections255 5a.25533an 534.Iundc tltatifthe building
does no u ntly have a tenant.that it is my ibility thea pan of the Date
requi is which must be to P Signature of AF plicant
All roof coverings to be Class"B"or better
W er or authori-red agent ate