09060042 CITY OF CUPERTINO
BUILDING DIVISION PERMIT +G�1 ' '�A ?R I }RAtTIJN�
BUILDING ADDRESS: PERMIT NO.
1 NA 1
OWNER'S NAME: PERMIT ISSUE DATE
PHORAXI A 8 8 9 CONTROL NO.
408) 3"'8-4018
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u p CLICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
X t, with Section 7000)of Division 3 of the Business and Professions Code,and my license is
'may in full force andc�ct� RPLC 3 WINDOWS & 1 DOOR LIKE 4 LIKE
j v�z License Lic. 0
3�O Datc Contractor
ARCHITECTS DECLARATION
C< I understand my plans shall be used as public recnrds�
DyU
L p y Licensed Professional
n y 3 OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
i
in o following mason.(Section 7031.5,Business and Professions Code:Any city or county
K m� which requires a permit to concoct,alter,improve,demolish,nr repair any structure
421 prior to its issuance,also requires the applicant for such permit to file a signed statement
s G 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
E y RE that he is exempt therefrom and the basis for the alleged exemption.Any violation of 14
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500).
❑1,as owner of the property,or my employees with wages as their sole compensation, 36611100. 00
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 docs 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 Law does not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
0 I am exempt under Sec B&P C for this mason
Owner Date
WORKERS 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 Worket's Compen-
.ion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
[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 am:
Cartier. 06/�n^�^CO Policy No.:492 DKRm I.12 00
CERTIFICATE OF EXEMPTION FROM WORKERS' j_�7;L
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 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.Dam—
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
,J O forthwith comply with such provisions or this permit shall be deemed revoked.
Z CONTMUCfION LENDING AGENCY
[~i I hereby alftrm that there is a construction lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.C.)
W�►,Q Lendces Name
Z Lender's Address
U O 1 certify that 1 have read this application and state that the above information is
4.O" correct I agree to comply with all city and county ordinances and state laws relating to
0 building concoction,and hereby authorize representatives of this city to enter upon the
Uabove-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 scenic against said City
U Z in consequence of the granting of this permit. Date
�. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued b3:
SOUK CE REGULATIO�. -
> Re-roofs
Si um of Applicant/Contractor ate—
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
is defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes XNo
If a roof
Will the applicant or(acture building occupant use equipment or devices which .s installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
strict?
❑Yes Wo
I have mad 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
a Certificate of Occu
Signature of Applicant Date
All roof coverings to be Class'J¢"or better
Ow or authorized agent date