00040113Nc DIVISION,v PERMIT
boo •
F=
t-.i LICENSED CONTRACTOR'S DECLARATION
O z . 0 1 hereby M. that 1 am licensed under pmvisiova of Chapter 9 (cotmuneing
F 4 t:� uu with Satinet ]000)af Division 3 of Ne Inumaxe and PenfcasionsC and my license is
cxzuV or full force goal <fi<e 3
wO' F Detey Q�
; u. v Conouw
.F u. O 11 ARCHITECTS DECLARATION
E I understeM my puns shall W used u public meads -
wa <o
t_ n � n , Licensed Prefeuionel
a
OWNER-BUILDER DECLARATON
z
1 hereby affirm that 1 am exempt from me Contractors License law for the
i = C following reason (Section 7031.5, Business and Professions Cute: Any city or county
a
to 3 " which raryira a pewit on eommtles, alter, improsu h permiN, or repair any "=.tore
priwto its issuance. also requites the applicant for such permit Lfilea,Law(nemment
Jut he is licensed panuans to the previsions of the a Boti sofa nicer law (Chapter r
tcs, he is xewim5 «don] 000) of Divisionl m theege exa and Frofeuiou Cade)=
Ws he is 3Ie b therefrom eM Ore burs for she alleged exemgim. Any vbonary of
Sxdon ]eel IS by any red cent es a permit aubjecu Jto applcant to a civil perWry of
not mom Nan Rve hundred dollam
❑ I, as ownerk rad du stray, w my employees with wag forsom Sec. compensation,
will MNework, Coe: structureienosinteMW Lxw dolor We(Set.]obi.Berof
and Properly who, Code: Tire Conuaa es License d w laws such sort apply s lf caner of
his nom who build. or improve tartan, afro who does such wort himself of through
for
his own employer.e provided that such impmv<muu em our intended o offered for
sale.ILhowever, Uu Wilding or I. of prm<nt 4 told wiminoreyurofmpose for sort
rf ead"m will Wve the Wrden of proving Net he did not Wild m impose for per"
pose of sale.).
L u owner of the See 704, am minus add conJecdng wish :) The Connector. .i t.
swat Jd esojot pply ]B44, w. of sad rty.1W Wi Code:) The s darer es, Li"
ceue law does tort apply to ts owner of property wce Wilds rs improver Norton, end
whence Law. for such projects with aconnmmds) licensed pursuant to she contractors
License law.
❑ I am exempt urear Sec. . B k P C for Nis reuon
Owner Dam
WORKER'S COMPENSATION DECLARATION
I WmbY aifiw undo peneitY of perjury one of the fallowing dcclentians:
❑ I have anW will for by Section 3700 oft a Labor Code. funs for WOrkeM1 ce of th-
tion, a provided for by Section 3]OO of the Labor Cade, for she Performance of she
_ Ik for Which ill9 pcmul is loused.
I have and will maintain Wnrtc /s Compensation Insurance, a required by Section
] _ofine Labor Code, for the performance ofine work for which this pewit is issued.
Vet set, a 4i3 85
n-664 04 f
El
Job Description
Tp
?Ile
(,i c@riZ G F 30 `fin- .ry Go
So. Ft. Floor Area Valuation
�j
K
,.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
- r
(This women need not be completed ifthe permit is forms hundred dollars ($100)
or lem.)
3
I certify that in the pedowmceof he work forwhich this pcwii is issued, I ahall
n
not employ any person in any me nano u w become mbjoi to Ne Workem' Compcn-
-
cation Laws of Celifomie. Date
Applicant
NOTICE TO APPLICANT: If, .fur making Nis Certificate of Exemption, you should
-
hemme subjot in me Worker's Compeualmn provisions M the Labor Code, you must
forthwith comply with such provisions or this pewit shall W domed revoked.
s .
CONSTRUCTION LENDING AGENCY
t.
I hereby affirm Nei mete iAaconstmNon lending agency forthm pedomunce of
ivod
rthe
for which this pewit is issued (Sec. 3097, Civ, CJ
Lendefz Name
to
Lemki's Address
a ,
tg7 A
1 certify mu I have read this application sod sum Nnt the above mforundmi ie
6t
correct. l agree to comply with all city and county ordinances atM stoic laws misting to
..
U Obuilding
construction. end hereby authorize expersenusives oft his city to enter upon the
v
fa. E~
above - mentioned Mosey for inspection purposes.
(We) egme m save, itMemnify keep Insomnia City
-
V
. t and the of Cupertino against
hostilities, judgments, costs and expenses which may in any way City
"
^ys tai
name Against said
in crosxc it cncc of the grmtng of this pewit,
- '-
r %
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON - POINT'
.Zi
SOUR CE�I/S11LGU U'S.
-
Signature of Applic UCoarmr Date
o t �, g„7,jw C.C,
HAZARDOUS MATERIALS DISCLOSURE
Re -roofs
will ft applicant wfnture Wilding eacupannmre or hmNe Woden ,material
an defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Coda, Section Z5532hy'
Type of Roof -
Yes wir"
Will the applicant or future Wilding occupant use equipment or devices which
cwt haurdoos air conuminanu ax defmW by me Bay Area Air Quality Management
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
District? —/
❑Y
I agree to remove all new materials for inspection. Applicant
g
I havxradme h,>uda,e,nso;W m�n;mme„ts wade, Chapter 6,95 of me Cali-
understands and will comply with all non point source regulations.
fender Hu1N B Safety Code, Stan. 25505, 25533 aM 25534.1 unintentional that if the
Wilding dots tort vicem Out it is my rnpomibiliry tonaif me pent
/� OD
of Nc tryuim h them riwmusuarceofacesmil /yt,XC
t
— //�
Signature of AppF cant Date
ownerw.yNorrz t
All roof coverings to be Class "B" or better
OFFICE