09020104 CITY OF CUPERTIN 7
BUILDING DIVISION PERMIT f , Y' *�
BUILDING ADDRESS: PERMIT NO.
OWNER'S NAME: PEIRMn'ISSUE DATE
2009
PHO A CONTROL NO.
408 499— 26
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I O p LICENSED CONTRACTOR'S DECLARATION O O O
V I hereby affirm that
Z with Sxtion 7000)of Division 3 of the Business and Professions Code,and my license is
'oy in full force and effect. REV CHG OUT 8 NEW LIGHTS;ORIG #08100181
D_ z license Chia Llc.r
±t Date Contractor
ARCHITECTS DECLARATION
un 1 derstand my plans shall be used as public records
�yU
y Licensed Professional
OWNER-BUILDER DECLARATION
g1 hereby affirm that 1 am exempt from the Contractor's License Law for the
i O following reason-(Section 7031.5,Business and Professions Code:Any city or county
10 P which requires a permit to cmuu•uct,alter,improve,demolish,or repair any structure
2 y prior to its issuance,also requires the applicant for such permit to file a signed statement
RG that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
a (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
.. that be is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7G31.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
not more than five hundred dollars(s~sao). 3 6 9 410 0 5 .MP p y Type
r❑1,as own of the property,or my employees with wages as their sole compensation,
will do the wort,and the structure is not intended or offered for sale(Sec.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 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
sak.)
as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sat.7044.Business and Professions Code:)The Contactors U. .
tense Law does not apply to an own"of property who builds or improves thereon,and.
who contacts for such projects with a contractors)licensed pursuant to the Contractors
License Law.
❑1 am exe p der Se .B 11 P C for Nis reason
Owo Date
WORK• ' C MPENSATION DECLARAT]ON
I hereby alum on
penally of perjury ore of the following deelaatfons:
❑1 have and will maintain a Certificate of Consent to self-insure for Workers Compxm-
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 fasumcc,as required by Section
3700 of the Labor Code,for the performance of the wort for which this permit is issued. '
My Workers Compensation Insurance carrier
and Policy number a :
Carrier. Policy No.:
CERTIFICATE OF F EMPI'[ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need nut be completed if the permit Is forone hundred dollars($I00)
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 man so to bceom suby t to tine Workers Compensation
Laws of California.Date C7
Appli=L i =
NOTICE TO APPLICA .I,a ter making l i ertificatc of Exemption,you should
become subject to the Workees Com. Ltio provisions of the Labor Code,you must
z forthwith comply with such provisions or this permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
(�r•-. 1 hereby affirm that inhere is a construction lending agency for the performance of
(x r� the work for which this permit is issued(Sec.3097.Civ.C.)
Lenders Name
z Lenders Address
U Q 1 certify that I have read this application and state that the above information is
LT. correct.I agree to comply with all city and county ordinances and state laws relating to
-C V building convection,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for Inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in arty way acme against said City
V z in consequence of the granting of this permiL n
APPLICANT UNDERSTANDS AND WILL COMPLY ITH ALL NON-POINT Issued by: Date
SOURCEREGU
2 Re-roofs
Signatu o pp utant/Contractor Datc
HAZARD ATERIALS DISCLOSURE Type of Roof
WTI1 the applicant or fut building occupant store or handle hazardous material
as defined by the Cupertino Mum (Code,Chapter 9.12.and the Health and Safely
Code,Sccuen2553ua>? All roofs shall be inspected prior to any roofing material being installed.
❑Yu No
Will the applicant or future boil ' g occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminates as coned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor.
nia Health&SafetyCode,Sc ors 25505.25533 and,"534,l understand that if the building
does not currently have a tenant.that it is my nsrbility to notify the occupant of the
requiremcn It must et 'or to of aCertifiicateofOccupancy. Signature of Applicant Date
O rorauthorizodagcnt Date All roof coverings to be Class'A"or better