00030049Ie PERMIT * IR Fo I , $
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LICENSED CONTRACTORS DECLARATION
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° 1 hereby Nat 1 em hernsed undo provisions of n LOUm,a mg
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ARCHTfECrS DECLARATION
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1 undersmW mY Plena ¢hill M used u Public records
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Licensed Proficau ..I
- ,OWNER -BUILDER DECLARATION
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1 hereby aRrm that I am exempt from to Contractors, License Law for the
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following reason. (Section 9031.5. Business and Professions Cade: Any city or county ,
which requims a Permit to construct, alar, improve, demolish, or repair arty strucwe'
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Sq. Ft. Floor Area
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prim to its issuance, also rox toes the applicant forxueh permit to rile a,iged statement
Met he is lianud pursu tat to the provisions o(Me Connectors Licenselaw (CMpda 9
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(aa,mnrnexempttir Saefixontion (ndMeasisn3afUaeegedeximdProA.,viCode)m
put he is Me bans for Ne Any
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exempt and violation of
alleged caempliato
anrtfrom
Section by anyydred Born for$ pemdt mbja. the epplicenno a civil penalty of
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t mom Nan five hundred toilers ($300).
Man
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❑ 1, a owner ofthe property, or my employees with wages as thetr¢ale compensation,
will doth. work, i n lthe structure iwm imerldW Pr oRead fonele (Sa.96f4. Business
ad Professions Code: i ' Comrsomua License law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or sluough
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his own employee. provided Nat such improvements art no intended or offered for
sale. If,however, Ne building or improvement is sold within one yearofcomyletion, the
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owner builder will have the burden of proving that he did not build or improve for put-
you f Isle
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❑ 1 - as i Me p of Ice property ,m sines and nn i ng with ) Tho
ConeWCt thC p(Ofttl (SCC 9814, Baxlnexa and Prafe6 ono Code )'Hie Contra,ore Li-
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cense Law does nut epPIY man owner of le party who bit Ids onmpmves thereon, and
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. who contracts for such projects with a contracpassionalr(il licensed passional to the Contractors
LicenseLm,"
❑ l am exempt under Sm. , B ffi P C for this on
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Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penally of perjary rote of Use following dalandiom:..
❑ 1 have alb will meinttin a Certificaa of Conunr mself--insure far Workers Compen-
tion, as pmvided for by Section 3700 of the Labor Code, for Ne performence of the
worlyfor which Nla Permit is issued. ', '�
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m/I have aM will maintain Workers Compensation Insurance, ea requimd by Section
3700df rhe lethm Codejor the perfmmaae of Ue work for which this permit isissued.
.MY Warkq�69)BIr Irµyrince carrier' and Policynptdbdam9�h,-ivy/Q/ry
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Currier. ((•
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
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.(Thin action neednm EemmPletedifthe permit ixforenecuralreddollen($100)
Or loss.).
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I certify that in theperformarme of Ne work for which this pemtit is Issued. IMail
U. employ any.... in any manner so as to become xubjat to the Warkeri Comps. -
Out. taws of Califomia. Dare
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, Youshould
bcmme subj ul 1. the Wmkels Compensation provisions of the Labor Code, you Most
foMwidh Comply with such provisions or Nis permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
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IhertbY affirm that them iseconswNon lording agency for peifomuna of
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the work far which Nis permit is ismed (Sa. 3097, Civ. C.)
Lenders Name
Landers Address
I certify door I have read this application and sora that to above iofomletmn is
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c. 1.1 agree In comply with all city eM county ordinances arta stat. lows behi ing m
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building consmiction,and hereby amhoriu relmearb,ives of this city to enter upon Ne
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- above-me,nioned Property for inspection purposes.
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(We) agree to L.O. indemnify and kap harmless the City of Cupertino against
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hibilitics.judgmems,Fos. and expenses which may Iran, wayaccrueagum, said City
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in coasequanceu g tingo"Ruporron.
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APPLICANT .R ANDS AND WILL COMPLY WITH ALL NON-P01N
SOURCE ' S. ..
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Signature ofApplnUCam c are
DOLS MATERIALS DISCLOSURE
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Will to applicant or future building occupant store orhanNelimuspousmaterialR
es defined by the Cupertino MV..'I Cods, Chapter 9.12, and the Health and Safety
Code. Section25532(u),Type
of Roof
Ely's No
I ill the appsicer,a,Maine Soldier if Occupant us, egaipmentordevices which
All roofs shall be inspected prior to.any roofing material being
uxe'vconw ire exdefinNbythe Bay Arco Air QueliryManagement
installed If a roof is installed without first obtaining an inspecttoi
District?
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❑Yes. }
I'agree to remove all new materials for inspection. Applicant
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un erstands ill'comply with,all non pointsource regulations.
Ihe,,road toha smarenalsro9airementsu Chapter 695 Of do Coli-
tomo Health ffi Se y o Sections ]5505, 255]3 and 8534. I understaM that if she
building does nae IY vearenank Nat it is mY mspomibiliry toswtifY Ne occupant
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of the rcymren i II be met P' Rsout. oft. Certifcare 077 pane.
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Signature of Apple Date
Owner or authorszed"IUas
coverings to be Class `B" or better
v OFFICE .