08050087BUILDING DIVISION PERMIT
BUILDING ADDRESS:
OWNER'S NAME:
ARCHITECTIENGiNEE L'
10 p LICENSED CONTRACTOR'S DECLARATION
U I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z with Section 7060) of Division 3 of the Business and Professions Code. and my license is
= y in full force and effecL
z Licmw Gas Le. s
Date Contractor
ARCHITECTS DECLARATION
u1 U 1 understand my plans shall be used as public records
u -y Licenced Professional
y OWNER -BUILDER DECLARATION
ii 1 hereby affirm that 1 am exempt from the Contractors License IJw for tie
'00 following reason. (Section 7031.5, Business and Professions Code: Anycity or county
% ii which requires a permit to construct, alter, improve, demolish. or repair any structure
Z prior to its issuance, also requires the applicant for such permit to file a signed statement
< 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 of
Semon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
❑ 1. as owner of the property. or my employees with wages as their soh: compensation,
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code The Contractor's I icense Law dolts not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employes, 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
rte.).
WE. sowner of the property, am exclusively contracting with licensed contractors to
nstrnct Ute project (Sec. 7044, Business and Professions Code:) The Contractor's U.
ease Law docs 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 exempt under Sec , B & P C for this reason
lI Q
VVDRKMrS,rOATION DECLARATION
I y affirm under penalty of perjury one of the following declarations:
7E;700
I hs and will maintain a Certificate of Consent to self -insure for Workers Compcn-
tion, s provided for by Section 3700 of the Labor Code, for the performance of the
ork for which this permit is I have and will maintain Workers Compensation Insurance, as mgtdmd by Section
of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Ihu section recd not be completed U the permit is for one hundred do0ars ($100)
or less)
1 certify that in the performance of the work for which this permit is issued. 1 shall not
employ any person III any manner so slm bee me b ecu to the Workers' Compensation
Laws of Califo Da
Applies
NOTICE Al D , # eking s Ccrtificae of Exemption, You should
become sWect to the Workers Compensation provisions of the Libor Code, you must
= Z forthwith comply with such provisions or this pctmit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
-+
4 1 hereby affirm that there is # construction lending agency for the performance of
Si .: the work for which this permit is issued (Sec. 3097, Civ. C)
QLenders Name
= Z Lenders Address
J 0 I certify that I have dead this application and state that the above information is
;i, `. correct- I agree to comply with all city and county ordinances and state laws relating to
3 U building construction, and hereby authorise representatives of this city to enter upon the
above-mentioned property for inspection purposes
(We) agree to Save, indemnify and keep harmless the City of Cupertino against
Cn liabilities, judgments, costs and expenses which may In any way acme against said City
,Z in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WI OMPLY WITH ALL NON -POINT
SOURCE REGU ONS.
Signature of Ifcan C r Dae
HAZARDO 5 AT ERIALS DISCLOSURE
r 1 the appll ant or future building occupant store or handle hrrardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes Al No
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑ Ya -'kat
I have read the hazardous materials mqubemens under Chapter 6.95 of the Califor-
nia Hculth & Safety Code, Sections 25505, 25533 and 25534.1 undersand that if the building
does not currently have a tenant. that It is my responsibility to notify due occupant of the
Certificate of Occupancy.
Owner
HIT31 wo OWN :.
PERMIT NO.
PERMIT ISSUE DATE
CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Job Description
ADDITION 280' MASTER BEDROOM & BATHRM ON THE
RIGHT
SIDE OF THE HOUSE.
Sq. Ft. Floor
APN Number Occupancy Type
36934037.00
Issued by:
Re -roofs
Type of Roof
Required Inspections
Date //— Z/' Q
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class in" or better