00020061CITY OF CUPERTIi
BUILDING DIVISION
HUILDING ADDRESS:
PERMIT CONTRACTOR INFORMATION:
.rxorvL:
ARCHITECT/EbIGINEER
° x,
Z Q i LICENSED CONTRACTOR'S DECLARATION
p I hereby affirm that I am licensed uder provisions of Chapter 9 (Consummating
with Sarcoma 7") ofDivision 3 of the Business and Prefessiom Coke, ad my license is
y E in full force ad effect.
s License Class Lic. B
°Oa
3 u. y Data
Contractor
ARCHIT'ECT'S DECLARATION
I understand my plans shall be aced as public mwds 't' -
rage' O O Licmad Professional
=
OWNER-BUILDER DECLARATION -'
1 hereby o inn that I am exempt Isom the Concurrences License law for the
wF o x following madman. (Section 7031.5. Business and Rofiau'mu Cade: Any city or county
3 $ which requh> a pored, to construct, alter, improve, demolish, or repur any sh some
poor to its Somece, also imprimis she applicant for such permit to rile a signed statement
than he is licensed Pursuant to the provisions of the Contractors License Law (Chapter 9
Icomurcncing with Section 7000) of Division 3 ofthe Buainesa and Professions Christ ne
•
that he is exempt tharefsom and she basis for the alleged exemption. My violation of
Salon 7031.5 by any applicant for a Purnell ubjects she applicant o a civil peruhy of
ism more ton five hundred dollars (SSM).'
Las owner of the pmpeny or my employers with wags as Heir sole compewdon,
will dome work, and me srructure is not intedd or offered for We (Sec. 7s44, Business
and Pierson. Cade: To, Contractor's License law fines net apply m an owher of
property who builds m improves thereon, and who des tech work himac f or through
his own employers, Provided thus such improvemmu art not unstudied or offered for
We. If, however, the building or imp.rourn la sold within one yese.f.culAttion. me ,
rider will have the burden ofproving that he did ism build or improve for pur-
e
owta:r of the progeny, am exclusively contracting with licensed cormse on in
v n
the psojem (Sec.7W . Bush. and Profession Cade:) The C.denco 's Li
eve cod «a napp an owner of peopeny who builds orimprov suteoo .and
Ft. Floor Area
4I'
0��20oG, j
0
Job Description -
leA -0e
>3 0c,0 h
Required Inspections
t.
Valuation
who '.comets Bch jecuwithamormactor (Olicensedrommodto eCommcmrs
License law r -
❑ lam as Pt u c . B& Nr mi reason ay
owner
°ale I �J✓ O /�/ U -
ORKFR'S COMPENSATION DECIARATIO y - '
• 1 hereby a/firm tiler perW ry ofpajury one of the followin6 dalantiov: V701 /•'(,/_�' ^d I .
❑ I have ad wie r or by a Section 37 a ofCoroabor self -insurt far Workers Comprise �✓✓✓! _."'("',��s�-__ _���'
cation, as provided for by Salon 3700 of stn Labor Cade, (or the perfomuoce of me
work for which this permit is issued. -
❑ 1 haveAd will maintain W pirlo Come ofthe w rkfor hi h his permit by Section s .
My ofines Co pdgfor nthe pence cander and work for r this pemtil is issued. -
MyWo rkda Compensation Insurance cetriaoli Policy number arc:
Cartier: Policy No,
O-
CERTIFICATE OMPE SATIONION PRAM WORKERS'
COMPENSATION INSURANCE ,
(This seninnn dnq be wmpleud if me pemrit is Toro «hurulndddlan (5100)
or less.,
Imnify that in the perfotmuceofthe work forwhich This permit is i.towL(Shall -- —
. not employ Any permit in any mentor m n m brooms subject m the Workers' Co.,.' _ -
sation Laws of California. Date
Applicam
. NOnCE TO APPLICANT: IL after making this Cenifica'. of Exemption, you should
bIcome mbjeano with Workers Comps., this previsions of the coeds Coke, you mull' '
forthwith Comply wire such psovisiana of this permit shallhdomed revoked.
CONSTRUCTION LENDING AGENCY
I hereby alEmt that there is a commiction lending agency for the performance of
the work for which this permit is issued (Sec. 3097.Ov. C.)
tw Landers Name
Landers Address '
Lzl Q 1 certify that 1 have read Ay.d�l i and sWe that me AMve infomuoon is A. correct. I agtm ro comply wire il o y oN' antts ad sum Isws missing to
7 Z building crostvction,uW hereby rva ofthis city'. ether upon the
U 0 abovemmumnd progeny for ins se -
kt •ew (We) agree to use, ind<mp lusmless the City of Cupertino against
f,J lul ihor..jdgments, cessation cxpenery which may in any, way acme.funn said City -
�t W is consequence of the grunting of this paurd.
06 APPLICANT UNDHRSTANDS AND WI LL COMPLY WITH ALL NON -POINT '
V z SOURCE. REGUII TUONS. -
signmrs ofAppucanU onunctor Dam - %�N7Dti v
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building meupam souse or hadle besadoYS mamdd Re -roofs I ,
as defined by the Cupertino Muni I Cokc. Chapter 9.12, and me Health and Safety
Code, Section z........ j Type of Roof - 0
, ❑Yes e - , °
Will the applicant or note i ingnecupar tuaee,ipmemordeoce.whieh All roofs shall be inspected prior to any roofing material being
cmitherudousurcontaminents defndbytheB.yAt QwiryMmave t installed. If a roof is Installed without first obtaining an inspection
• ° "n`, l agree to remove all new materials'.for inspection. Applicant
Yes o d
Ih.ve _ h a, matdahm9niremen .aadet�hapRrh.95nfineCaii-
understands and will comply with. all non point source regulations.
forme HeAIN Sid , Sections 255 5,25533 and 25534.1 undo d shat if e -
hoildingdoesotca haveamnu91 t�7 /fail }s my respovibiliryto l{�'^In occ I -
ofine«yu' ms A PyP mph dt/mrf riva;FOfaccuifg6k o Oc '
.gaol
of Applicant
All roof
OFFICE
Date
gs to be Class `B" or better