06100092 CITY OF CUPERTINO 7777777777777
BUILDING DIVISION PERMIT =ORbii
BUILDING ADDRESS: ABLE SEPTIC PERMIT NO. 06100092
22100 STEVENS CREEK—BI31D
OWNER'S NAME: PERMIT ISSUE DATE
CITY OF CUPERTINO 1020 IRIJEE DR in'/I 9119oc)G
SNE:
SANITARY NO. CONTROL NO.
(408) 377-9920
ARCHITFCT/ENGINEER
08 377-
ARCHITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACT'OR'S DECLARATION
m` I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
Z with Section 7000)of Division 3 ofthe Business and Professions Code,and my license is
�y in full force and effect. REPLACE SEWER LINE
t Z License Class Lic•8
F aDate Contractor
• ,,,t ARCHITECT'S DECLARATION
,a
< 1 understand my plans shall be used as public records
u. Licensed Prufcssional
y OWNER-BUILDER DECLARATION
3< 1 hereby affirm that I am exempt from the Contractor's License Law for the
:
:00 following mason.(Section 7031.5,Business and Professions Cale:Any city or county
which requires a permit to construct,alter,improve,demolish,or repair any structure
Z} prior it)its issuance,also requires the applicant for such permit to file a signed statement
=o that he is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area Valuation
h (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 of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3AM1QQffib'kr. 00 Occupancy Type
not more than five hundred dollars($500).
(:11.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 forsale(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-
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 Taw 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.
❑I am exgrnr Sec B&P C for this reason
Owner'16.1 Pte_- Date
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 Workces Compen-
sation,as provjdcd for by Section 3700 of the Labor Code,for the performance of the
work for wjtidt this permit is issued.
I vac and will maintain Worker's Compensation Insurance,as required by Section
7dD 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. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE O
(This section need not be completed if the permit is for one hundred dollars(S 100)
or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date I o1
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
=z forthwith comply with such provisions or this permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
.-4 w.. 1 hereby affirm that there is a construction lending agency for the performance of
Si> the work for which this permit is issued(Sec.3097,Civ.C.)
4 Q Lenrices Name
=z Lendees Address
J 0 1 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
Ubuilding construction,and hereby authorise representatives of this city to enter upon the
a above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
r. t;4o) liabilities,judgments,costs and expenses which may in any way accrue against said City
J z in consequence of the granting of this permit.
APPLICANT UN RSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC ONS.' �,.
Re-roofs
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as dcfrncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
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 dined by the Bay Area Air Quality Management all new materials for inspection.
District?
[3 Yes C:1 No
I have read the hazardous materials requirements under Chapter 6.95 of thc Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if thc building
does not currently have a tenant,that it is my responsibility to notify the occupant of the
rcquircrpefus must be met prior to issuance of aCertificatcofOccupancy. Signature of Applicant Date
Owner or authorized agent Date All roof coverings to be Class"B"or better