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CITY OF CUPERTINO
BUILDING DIVISIONklle
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BUILDING ADDRESS:
PERMIT NO. 05120116
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby 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 forte and cffccL
FRONT MODI FI . /CALIF-. FRAMING
License Class Lic.#
Date Contractor
OVER BAY WINDOW
ARCHITECTS DECLARATION
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 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 file a signed statement
Sq. Ft. Floor Area Val 0 0 0
that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9
ua*&O
(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
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 (S500).
37528002.00
❑ 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 forsalc (Sec.7044, Business
ns
Required Inspections
an owner of
and Professions Code: The Contractor's License Law does not apply toe
9 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 owncr-
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 licensd contractors to
construct 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 eontracto licensed pursuant to the Contractor's
License Law.
,
❑ I am exempt under Sec. , B & P C for this reason
Owner
W S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
-
❑ 1 have and will maintain a Certificate of Consent to self -insure for 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 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 are:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(17tisscction teed notbe completed If the permit is for one hundred dollars ($100)
or less.)
1 certify that in the performance of the work for which this permit is issued, 1 shall not
employ any person in any manner so as to become subject to the Workcrs Compensation
Laws of California. Date -a
Applicant
NOTICE TO APPLICANT: If, m sir g mg is Cem ption, you should
become subject to the Worker's Compensation provisions of the Labor Code. you must
forthwith comply with such provisions or this permit shall be deemed revoked.
I
' CONSTRUCTION LENDING AGENCY
l
1 hereby affirm that there 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
j I certify that I have read this application and state 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 authorise representatives of this city m enter upon the
.
above -mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgmcnu, costs and expenses which may in any way accrue against said City
in ran consequence of the gting this permit. APPLICANT
APPLICANT UNDERSTANDS ggqNNND WILL COMPLY WITH ALL NON -POINT
Issued b Date
SOURCE REGULATIONS. /
Z ins
Re -roofs
Signature of plicawuacto� Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant store or handle hasardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section zss3z(a)?
C) Yes 16No
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
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?
[3 Yes No
I have mad the ha2ardous materials requirements under Ch2pter6.95 of the Califor.
nia Health & SafciyCode, Secvons 25505.25533 and 25534.1 understand that ilthc building
does not currently have a ten at it is my responsibility to notify the occupant of the
requirementswhich in t el prior to issuance of a Certificate of Occupancy.
Signature of Applicant Date
.� /:;i ° t
All roof coverings to be Class "B" or better
Owner or authorized agent Date