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W3LL
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rY OF CUPERTINO '
BUILDING DIVISION PERMIT
)ING ADDRESS: t
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nei I am licensed under provisions of Gnawer 9 (comment
wish Section ]OOOJofDi 3mf the Business and Pemf�essn'o�ni Code uipd myli<ena
in full force send effect
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Job Description -
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a a� o Wanted Rolcssioml . -
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OWNER-BUILDER ex ERDECLARATION
1 hereby effrm that 1 am exempt from to Contractor's Wce w Lew for the
P Z O "following martan. (Section W31.5. Business and Pro&ssiona Code Any city m county
u«i °
which resfires. ;permit to construct, aler, improve. damohsh repo, any rwcono S Ft Floor Area /T �a.� Valuation
t.3= pit tots issuance, dso regems the applicant fors «h permit to flee signed statement
q'
Net he le littnud purswnuu the Provlwom of dre COntrecwr. License Lew (CMPer9 Vim'
(commencing wWSecion] WO )ofDivlsion3ofNeBusinessmanr,u costonsCOde)m - s pNNumber - Occupancy Type
Nat he s exempt therefrom and de basis for the alleged ex pima Any yaolation of 1 5
Seel ]0315by anyapplicn tfmapemitsobmtithe&"Is nttoacivil Nnet! �G (9-77 -, _
m Ines f l u tiled dollars (3300) - -
❑ 1 mownerartevrovery; armrampmree .wtmw . geeyman.aie6ampem.dan, ' - .Required Inspections -
wiildoth.wod,andthe.wcturei. trots.... dtdmoffWdfmsalc(S «:]090,Bmm. yon
and Professions Code: The Coomsetor's License law dons and apply to an owner of
proper, who builds m improves Neeos, and wlm does such work himself or through
his own employees, provided that mch improvement. tee not intended or odered for
sale If, however, the buddingmimpmvemem is sold wrtin one yeuefcompletion,the + - ,a
•' owner - builder will have the burden of proving that he did and build or improve for pur- pose at..[..), •• r.
1, as owner of the property, met exclusively contracung with licensed contractors to
onswci the project (Sec. 7060; Bu,m.sa teed pmfessiorm Code) The Contractor's Li-
came taw does nos apply to an owns of property who builds or improves thereon. and _ 1 _ 41'
who contracts for Inch projects with a conoactods) licensed punumt to the COnvana'S'
License Law. A .41 ' .
❑ I mn exempt under Sec. '.B &P C far this reason
Owns .. - Care
WORKERS COMPENSATION DECLARATION L
1 hereby Wirt, mrshor penalty of Pe J rY one of the f0cosm, declarations
❑Ihave end will mainain a Cen.ficate ofCOneoUaselfansure far Worker Corona. •, !/ -
saban, as provided fm by Section 37W of the Labor Cade, far the performance of the o
work for which this permed I. I ... ed, '
E] I have and will ..main W rker Compensation insurance, m required by Seems -
3700oftheLaWrCode for the perfrtrantt ofthe work fm which Ns words is issued. r
My Worker j�°,Q'pem met tt tamer and Policy n
Cemcc +-- '�r..rr-- $�{.l� /�n�{ Policy NO.00,107 �W^
CERTD9CATBEXEMPTION _ � '
COMPENSATION INSURANCE
.(This section need amt be completed ifthe pcvnit is foronehundrad dollsra(SI00) 1.
employ my thaturnin my manner of the wodrnesubje Nis the Worsiss'e Captain-
_ .dotemDloY any lxrsori in any manor, so asmhecome.ubj«tto the Workers Cmmpen-
swim. Laws of C.1ifomia: Data '
Applicant `-
NOTICE TO APPLICANT: If, after making this Cenificae of Exemption. you should
` become subject to the Workers Compe.tardn provisions of the Labor Cnde, you mmt ..
forthwith comply wit such provisions or this permit .lull be dame, revoked.
Z ' , CONSTRUCOON LENDING AGENCY -
010 Ihreby aft tat s e der lending agency f the parfrmaroe of
�r themkf which thipmmt I. issued (S Cis. Y _
Eta Lenders Name +✓ r 3
a Lender Address ., .
[� A ' 1 Addy to 1 ba a read this application and stare that
to above mfomabon is -
�u tort«[ 1 agree to comply t all city and county ordinances and sate laws relating 1.
U 0 building costrued.. and hereby amhmiu specalnWises of this eery no enter upon the J ^t
abovo-memimied pmpeny for Inspection p rpmsa.
W E;a (We) agree to rave, indemnify and keep har.nla. the City of Cupertino against _ 1 -
,O V liabilities, judgment., Casa and ca,..r which may in any way scene i,mmt said City
�•r r:i m..'equcaccafthegmndngof WspmmiI.
Fn C•t APPI,IC U'D1RSfA Og AND W1L_LCOMPLY WITH ALL�N O {{J %- POINT r
U
SOUR : RE
91pmtue of Applic'HAZA DO , ���/✓,� �' i�•�w��DU a
HAZARDOUS MATERIALS DISCLOSU
Willy the Cicant or fwurc Wilding Cad Cpanumrcor handle Heads and Safety
Re -roofs
ns defimA by the 32m)7 o Munam al Cad Chepe 9 12 and t Halt end SaF ty
El Into. Code, s«ua. x553z(u+ _ - Type of Roof
Will to impleept or future building occupant use equipment or0 Ices which All roofs shall be inspected.pfior to any roofing material being'
mrlhavrdW.mreanymlmn nedbytheBayArcaAirQualityMamgem ant installed., If a roof is installed without lrstobtaining an inspection
Di, , I agree to remove all new materials for inspection: Applicant
I have mad the haaardous ma amluimmenm under Chapter 6.95 of dr Cali Understands and will comply with all non point source regulations.,
tome Had sty . S form 505, 25533 and 25530. I unheurid Net if the'
building❑ 'nmc t ve mnant, at it is my responsibility m maify Bon occupant .. ,
.s of the rega' a st p'mmusuatee a CendwareacteuPamy. --
41 Signature o£Applicant, '' Date - r
j'O.onrm. o agent _ ,Dam t - I
c . All roof coverings tor be Class, `B" or better
OFFICE