00020139 CITY OF CUPGRTINO �xr�3352f..wr.s.' 55�5'`•._r.8•rn:.RH >r• 'f.�n`?M• y PERMIT No.
BUILDING DIVISION PERMIT 94GONTRACTOR41NF0RMATION:F-1 lo Q .(J ,2 0 / 3 (�
BUILDING ADDRESS: I
1! ' SANITARY NO. APPLICATION SUBM LDATE
OW ER'S AMG: 1 �`5 ,_
Ntc CONTROLX
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r i LICENSED CONTRACT'OR'S DECLARATION
Z:— I hembY.firm Nat I.licensed render previsions of Chapter 9(cammemine Job Description
0 t_u� withs 1h...0(10)ofDivision3ofthesednder pr Prorusiof Code, 9(comiewi is
Hu�U in full force end affect. New +W o - c►� qQf g e.
License Class Lic.X • Y
a a y Dme Contractor
F
O a ARCHITECTS DECLARATON
understood p y P
J I underend my plans andl used as purecords
rds
00 Licensed Pmfessica d
vi^ OWNER-BURDER DECLARATION
Z a 1 hereby affirm that I em exempt from Ne Camracmla License Law for the
5 F O following reason.(Section 703 1.5,Business and Professions Costs:Any city or county
C which retlums a Permit m commict,Wier,improve,demolish,or repair any swetwe
dam S Ft FIoo2 sea 1 �Valu�tior� 0
Prior m its issuance,also re,mor the applicant for such permiuo file a signed armorial
q•
that he is licensed pursuant to the provisions of the Convectors Lic.m Law(Chapter 9
(comm"ncing with Section]000)of Division 3 of the Barium and Professions CW.).,
Ilan he is eaempt therefrom and the basis for the alleged excmpioa Any violation of APN umber OCcupanl y Type
Secdan 1031.5 by any applicant for a pemtil subjects the applicant to a civil penalty of (a
not mom Nan five lumber!dollars($500).
❑Lasownecarthemvperty,armyemPloyeeawithwages.thdrroI.,mu'ncafon, Required Inspections
will do Ne work.and thesmtdum is Inst intended or offered far sde(Sec.1040.Historic.
end Professions Code:The Contractor's License n law donot apply to an owner of
property who builds or improv.Nemo.,and who does such wmh himself es through
his own employers,provided that such improvements she ria imerde i m offered for
vle.lf oweve,thdwtlding"'improvement is sold within one yesro(completion,the
o wilder will have Me burden of proving that he did not build or improve for par
e`of.Ithe
nowntroffla,propcny,em exclusively contr.ting with limned mn r tma m
I the pmjm(See(S70F1.Busimats and Professions Code)The Convenors U.
,cenu law dace nota ly m an owner of property who Wild..,improv.thcrton,sed /
w1mvent.ns m pmjecawiNacom.emr(s)licen.Mpunuentm Ne Con"cmr1
License La j
Me m
❑Mot r5B&P or this no
Own. I
WORKER'S&YAPENSATIONDECLARATION - O!
I hereby affrm under pendsy of perjury one of the following declarations:
have end will Zroam.Cmifce.ofConsenno.If-insurt for Worker'a Co.Pen-
r.as provided for by Section 3100 of the Labor Cade,for the performance of the
mk for which this permit is rowed.
I have and will maintain Wmker.Compensation Insurance,as mquirtd by Section
31000(the labor Cade,for the performance of the work forwhich this Permit is i...ad.
My Workcr s CompenoJon Insurance carrier and Policy number m:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit isforone hundred dollen(510))
or less.)
1 certify that in the pedo..of the work for which this permit is named 1 Wall
not employ any parson in any manner so as to become subjen m the Warsaw Compen-
sation Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenifi.m of Exemption,you should
become subject to the Wesk"rs Compm.0on provision.of she Labor Code,you must
forthwith comply with such provisions or this permit Melt be deemed revoked.
CONSTRUCf10N NO AGENCY
Q I hereby uffmt Manthem iso const nion lending agency for the paformawee of
y the work far which Ibis permit issued(ge.3WO.Civ.C.)
(~ )enders Name
�i 7 lenders Address
fzt G 1 certify that I have reed thi ani n tate Mal the.hove irdomation is
V O
building 1e6rte to<omPIY with elle n cot ' or Ism and'uvIowa relatingm
g conawnion,and hereby out romp aenmtivn of thiaaity to enter upon the
ebov (WO a ed propertyss.for emnech n pier,h
0 F.U (WO egr.m cove,indemnify end keep hartnlna the City to Cupertino id Cry
0 V inconse;enceofnts amoand..,.awhichmay in anywry aroma agalnrt trod City
} k37 APPLICANT UNDERYI ft ANDS AND
this pentyl.
U (APPLICANT ULATIOI'ANOSAND WILL COMPLY WITH ALL NON POINT
L.) � SOURCE REGULATIONS. `.=•r �-1� �__�
Signawm ufApplicandConvanor Data ,�111 \ ��•t/�/,—�](lC!%
HAZARDOUS MATERIALS DISCLOSURE V n�tiroti, .JCC'
Will the 4MItcam or future Wilding excupemnom he handle haaardoas material Re-roofs
as defined by in Cuapte
nino Muni'Fel Cod",Chr 9.12,and the Health end Safety
code,Seedan 253321`). Type of Roof
❑Yes No
Will the epplicaut 4tumWilding occupmt use equtpreem or devices which All roofs shall be inspected prior to any roofing material being
.it mous. un air mnammmv defined by the Bay Ar.Air Quality Management installed. If a roof is Installed without first obtaining an inspection
strict?❑Yes I a ree to remove all new materials for inspection. Applicant
Ihave ,t the hamdwusmamddsraluimtenaunder Clapter6.95ofthcCall- understands and will comply with all non point source regulations.
forma h al*Code.Sessions 25505,25533 snd 25534.1 a and this if the
Faildi d ."I h hours.1.m itis myresponslar1hy utif11=p.t
Y c
ofth 9u n`uwlusl, 1 fp seta issuanmofaC` fITc 1
Q//� l � t� �1 I Y�J Signature of Applicant Date
omna-moolousired agent Dam
All roof coverings to be Class"B"or better
OFFICE