00020066CITV OF CUPERTINO
non•mNCnrvlSION PERMIT, ' CONTRACTOR INFORMATION:
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AkCIIITECT /ENGINEER
,• i LICENSED CONT/IACn DECLARATION
under p ,
I hereby affirm Nu 1 an liccnsid uer provisions of Cluptci 9 (comnetring
ad a in fimulll forcifamn7000)afDivision3of theBnimsa and Profnsions Cade `and my license is
e W effect.
d 0 a Licenx C an M
c N Dne Conomuu _
O ; . ' ARCHITECTS DECLARATION
1 un&ntmd my plans shit be used n public mwNs 1.
d ad' O Llca,sed ProfeatimW
_^ y OWNER - BUILDER DECLARATION
!"' ¢ 1 hereby, affirm that 1 am exempt from the Convector. License Law for the
following rcaem. (Section 7031.5, Business and Professions Code: Any city or county
e 3 m whim requires a pemtit to construct. alter, improve, demolish, m repair any mosom e
prior as its issuance, also requires the applicant for such pannier o file a Signed statement
the he is licensed pursuant to the provisions of the Ci n m m r License Law (Cbaptn 9
(commoniag with Section 7000) of Division 3 of the Business and Pedfessiom Code) or
dust he is exmpt Biaefrom vd the bads for the alleged exemption. My violation of
Samm 70313 by my applicant for a permit subjects the applicant a civil penalty of
not mom Nan five hundred dollars ($500).
- ❑ I, as owner of the Property, m my employees with wages u their sole compemation,
will do the work. and the mudure is not intended or offend fora.). (Sec. 1144, Hart.,.
W Pectination, code: The Contractor's Licenx U. don and apply t. an ,weer of
property who bolds or improver ft... and who does such wmk himself or through
his own employees, Provided me, such Improvements arc no intended or offered for
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Sale. 1 owevcr the budding or improvement is Sold wimp one year ofcompleim, par
own - builder will have the burden of pmving that M did not mind or improve for par
I'd ax I.
1
in owner of the p party m ncluvvely eomm�hng wlm l net comacron to
t me "mac 1 (BpC 77(40, Business and Pmfrasmns Code) The Contractor's Lb
cenelaw doegpat ply, an owns of property who bmldx or improve, mereom erd
. i Job Description
PERMITNO.
000200(;,
\NITARY NO. AFPLICATIONSUBMITTA
'N /C CONTROL#
BU1,111NO PERMIT INPQ
S Ft. Floor Area Valuation`
�. 2S
3 ' APN Number O^ OcculAincy Type
.. . Required Inspections t -
ONG
OFFICE
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I hereby affirm sad, Fnishy of perjury one of me following declaration:
T t ,. - „ , , ,
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l have and will maintain a Certificate ofCommnnu self -insure for Workers Conran
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t.
Salim, as provided for by Section 37W of me Labor Code, for the performance of the
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work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation less., as required by Section
3700ofthe Labor Code, for the perfnnexamecame work for which Bits permit is lamed.
s
My Workers Compensation Insurance catrin and Policy number am t
r t '
Carram, Policy No.:
CERTIFICATE OF EXEMPTION MOM WORKERS'
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COMPENSATION INSURANCE
(This action sued not be completed if the permit is forone hundred chinum ($too)
or less.)
i certify thin in the per(orrtunceofdbe work for which this pemut is issued, I Shall
not employ any person in my manner ro as to Become subjmuo me Warken' Colman.
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sadion Laws of California. Dew
Applicant
NOTICE TO APPUCANT. 1( after malting this Certificate of Exemption, you almuld
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become, subject to me Workers Compensation #minis ons of me Labor Cade. you must
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forthwith comply with such pmvisium or this permluhall be d.emed revoked.,
, STR
CONUCTION LENDING AGENCY
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p
.atro n lending.9.rq for the perfommi. of
I thereby oifem thin them is a nm
"me
work for which this perm, is leased ('n. 091, Civ. C.)
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1<Mres Name
ya
IaMers Address
• f:7 ,A
1 certify that 1 have read mica p a an um thenhe above infomudon is
eeeq...
correct. I agree to comply with all c y std u o mines tad suw laws relating m
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building concoction, and hereby authorise representatives of,hiseity to emerupon the
above - mentioned pr rt for inspection purposes
far E.,
(We) agrx t. a ine, indemnify and keep harmleat the City of Cupertino agent
Q f)
nd nPenxemit. uuYin any wry acme abainsl said City
Iicmince
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of me griming Nis
inconsequenceN
,
Eof
WILL
APPLICANT UNDERSTANDS AND WILL COMPLY WI fII ALL NON-POINT
W
f..) Z
SOURCIiREGULATIONS.
9
ySignature
of ApplicantlContrmtor -. - Daw
19M'Jn -rUCGh
HAZARDOUS MATERIALS DISCLOSURE
' wnme. ppunntarf. mrewudmgecnpantatarearnmelenararaamamawrid
Re -roofs .. -
ax def ned by the Cupertino Munici I Codr, Chapter 9.12, artd the Healm and Safety
'Coal, Section sss32a)1 ' i ., -'Type
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of Roof
[)YO
' 'Will the applicant orfnum building occupent use equipment or devices which
All roofs shall be inspected prior to any roofing material being:
emit hicureclosse air contaminants as defined by the Bay Area Air Quality MaWagencent
installed. If a roof is installed, without first obtaining an inspection
El o
I'a ree to'reinove all new materials for inspection.' Applicant
g
d
understands and will comply with all non point source regulations.
„Sew c ncrods tam n nndnGnap 695afN Gai-
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foram Health of y . Sections O5, 25533 end 2553a.1 u - ,uu1 thin if the
building does od cu seat oan is my responsibility ify me Sport
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of the m u rats h met s n' rte I
Signature of Applicant Date
Owner miumarboadigi,m '. Daw
All roof coverings to be Class "B" or betfer
OFFICE
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