07090111 CITY OF CUPERTINO
BUILDING
1
D DIVISION
+BUILDING ADDRESS: i ^i. s>t;:::r.::.. ....::::.:•..;> ::;:`';`V'';>ri >`'s?'z.
21741 ALCAZAR AVE TBD TO BE DETERMINED PERMIT 709O.
.) 07090111 ,
•
111/15/2007
PHONE: � SANITARY NO. CONTROL NO.
ARCHITECT/ENGiNEIsR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
.0 p` LICENSED CONTRACTOR'S DECLARATION C�
U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
z with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADD LIVING ROOM
�y in full force arts effect S. LAUNDRY & BATHROOM
? License Cl s. Lic.M
Date Contractor 41 r—e*_ 9C 7-- .
f ARCHITECT'S DECLARA ON
g e I understand my plans shall be used as public records
0.
:O y Licensed Professional
y OWNER-BUILDER DECLARATION
ai t% I hereby affirm that 1 am exempt from the Contractor's License Law for the
1:0 O following reason.(Section 7031.5,Business and Professions Code:Any city or county
,4 which requires a permit to construct,alter•improve,demolish,or repair any structure
o Z prior to its issuance,also requires Use applicant for such permit to file a signed statement
that he is licensed pursuant to Use visions of the Contractor's License Law(Cho ter 9 S Ft.Floor Area
c` P p° P q.
�=
$85000
Valuation
t-$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y 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 Number
not more than five hundred dollars(5500). 3 5 71 9 0 2 0�� Occupancy Type
❑1,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(See.7044,Business
and Professions Code:The Contractor's License 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 arc not intended or uttered 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.).
O 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 Use Contractor's
License Law.
I am exempt under Sec. B&P C for this reason
ner Date
WORMS 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 far Worker's Compen-
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 Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
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)
mr 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 sq ss/brg% Jb jeci to the workers'Compensation
Laws of California.
Applicant
NOTICE TO APIFLICAA : r making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith 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 Use performance of
OG> the work for which this permit is issued(Sec.3097,Civ.C.)
(ta A Lender's Namr
Z Lenders Address
V Q I certify that 1 have read this application and state that the above information is
UL " cored.I agree to comply with all city and county ordinances and state laws relating to
0 F" building construction,and hereby authorize representatives of this city to enter upon Use
HV above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless Use City of Cupertino against
.c to liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of the granting of this permit.
114 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued f y: Date
SOU�R ;IAT�0�. /'') �� Re-roofs
S`i at/Conuactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Use applicant or future building occupant store or handle hazardous material
'eftned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
>c.Section 25532(a)7
❑Yes All fool's shall be inspected prior to any roofing material being installed.
lt7fNo
/� If a Too~is installed without first obtaining an inspection,I ill the applicant or future building occupant use equipment or devices which g agree to remove p g
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes I17T(o
I have mad the hazardous materials requirements under Chapter 6.95 of Use Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.I understand thatif the building
does not currently have a ten tit is my risibility to notify Use occupant of Use
requirements w' met artoissm�aCcnirx=oroecuppaey Signature of Applicant Date
t All roof coverings to be Class"B"or better
Owner or authorized agent Date' g