09040071CITY OF CUPERTINO
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BUILDING DIVISION PE1<LYIJLT�.
BUILDING ADDRESS:
PERMIT NO.
OWNER'S NAME:
PERMIT ISSUE DATE
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A2099
CONTROL NO.
ARCH7iECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I herby affirm that I am licensed under provisions of chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full fore and effect
ADD 890' LIVING/DINING RM EXTENSION, PORCH, FAMILY
License Class Lic. g
.
Date Contractor
RM, MSTRSUITE, WALKIN CLOSET/BATHFM, 3 ' EXTENSION @
ON
Iunderstand ray platushal �S�sp eicrrecorrdss
BCK—RMDL 196' LIVING/DINING FM, KITCHEN, BEDRM, WATER
Licensed Professional
OWNER -BUILDER DECLARATION
I herby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that he is licensed pursuant to the provisions of the Contraclors Deena Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
that he is exempt sbemfrom and the basis for the alleged exemption. Any violation of
15 0 0 0 0
APN Number
Occupancy
P Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
five
not mom than hundred dollars (S500).
36216033.01
❑ I, as owner of the property, or my employees with wages as their sole compensadon,
will do the work. and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Codes c The Contractors Lie Law does not apply to an owner of
Required Inspections
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 ale. 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
sak.).
. u owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec 7044, Business and Professions Code:) The Contractor's U.
case Law does not apply to in owner of property who builds or improves thereon. and.
who contracu for such projects with a contractor(s) licensed pursuant to the Contactors
License Law.
❑ I am exern B k P C for this reason
Owner M�_ �_
I herby affirm under penalty of perjury one of the following declarations:
❑ 1 harc and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided Rr by Section 3700 of the Labor Code, for the performance of the
work for which this permit Ls issued.
❑ I have and will msinuu m Workers Competnation Irsurarnz, as required by Section
3700 of the Labor Code, for the performance of the work for which dries permit is issued
My Workers Compensation Insurance artier and Polity number am:
Carrier. Policy No.:
CER11ECATE OF E MMPITON FROM WORKERS'
COMPENSAMON INSURANCE
(This section reed not be completed if the permit is forone hundred dollars ($100)
or less.)
I certify that In the performance of the work for which this permit is Issued. 1 shall not
employ any person in any manner so e subject to the Workers' Compesadon
Laws of CaliformoeMis(y
Applicant
-
NOTICE TO APCANT.. If, alter making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this petmil shall be domed revoked.
CONSTRUCTION L EN'D WG AGENCY
I hereby affirm that them is a construction lending agency for die performance of
the work for which this permit Is issued (Sec. 3097. Civ. C.)
Lenders Name
'
Lenders Address
1 certify that I have mad this application and seam that the above information is
correct- I agree to comply with all city and county ordinances and state Laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
ahoy mcmioned property for inspection purposes
(We) agree to am indemnify and keep harmless the City of Cupertino against
Iiabilida,judgm"LL casts and expeasa which may in anyway acme against mid City
in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued b q
y:2�Date ��—
of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the appicant or future building oceupantstomor handle hrmrdous maicrixl
as defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(a)T
All roofs shall be inspected to any roofing being installed.
❑ Yes; /.�No
Yes
prior material
If a roof is installed without first obtaining an inspection, I agree to remove
P g
Will the applicant or future building occupant use equipment or devices which
emit harsrdow air contaminants as Wined by the Bay Area Air Quality Management
,
all new materials for inspection.
District?
❑Yes No
1 have read the hanrdau materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505. 25533 and 25534.1 understand that if the building
don not currently have a tenant. that it is my responsibnily to nodfy the occupant of the
regalre�� awhich must bemet prior toissuance faCertincate�grcu� y
1
Signature ofApplieant Date
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All roof coverings to be Class 'n " or better
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OwnciD�wlhori�rd
agent Date
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