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CITY OF CUPERTINO
PERAUT
BUILDING DIVISION
YES BUILDER
BOIL I�inV'SP'ALOS VERDES CT
PERMIT NO.
08060129
(4 0 8) 8 6 6- 8 3 5 2
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description.
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70W) ofDivision 3 of the Business and Professions Code, and my license is
REVISE TRUSS CALLS DRAWINGS — ORIG #07040073
in full force and effect.
License Class Lie. S
Date Contractor
ARCHITECTS DECLARATION
I understand my plans shall be used as public mcords
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
fallowing 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 file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sy. Ft. Floor Area
$ 0 Valuation
(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
3 5 6 210 3 3 Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars ($500),
.
❑ 1, as owner of the property, or my employees with wages as their sole compensation,
RequiredIns Inspections
p
will do the work, and the structure Isnotintendedoroffered for sale (Sec.7044,Business
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended oroffered forsale. 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.).
I, as owner of the property, am exclusively contracting with licensed contractors to
co tract the project (Sec. 7044. Business and Professions Code:) The Contractor's Li.
tense Law does not apply to an owner of property who builds or improves thereon, and,
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
I am exempt under Sea B & P C for this reason
Owner z
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-imum for Worker's Compen.
scion, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I 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 Warker's Compensation Insurance carrier and Policy number am:
Carver, Policy No.:
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is formic 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 az becomersub1 et to the Workers' Compensation
Laws of California. ate �
of Exemption, you should
become subject to the Workcrs Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this pgrnit shall be deemed invoked.
' CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above information is
corect. 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
? above -mentioned property for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
I liabilities,judgmems, costs and expenses which may in any way accrue against said City
in consequence of the of this permit,
granting
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGyL
-roofs
Type of Roof
Signature of Applicant/CoUractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as 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 �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 as defined by the Bay Area Air Quality Management
all new materials for inspection.
District? j
❑ Yes IYI Nu
i have read the hazardous materials requirements under Chapter 6.95 of the Califon-
nia Health & Safety Code, Sections 25505, 25533 and 25534,1 understand that if the building
does not
of occupancy.
Signature of Applicant Date
W/_/
All roof coverings to be Class 'A"' or better
Owner or authodxcd agent Date '