00040034TY OF CUPERTINO
BUILDING DIVISION IDUDAd17`
S. gt,"l atrc ':
VHRgT VI LI IK7 Y I 7
PHONE:
ARCHITECr/ENGINEER
111101 L aL' q ■ TlGii�/flJec
UI SEDCONTRACrOR'SDECLARATION. -
1 hereby affirm mat 1 nm licensed wades pmi[imc of Chapter 9 (commencing s
with Socum7NIE.d Division Sof the houses, and Profe,.ion[ Code, W my Ecense is
in full force W affect.
License Class Wc. sl
Data Costrclos
- ARCIf ECPS DECLARATION
.I odermead .1plans shall be used az public retold.
Llcrosed ProfcaerarW
OWNER-BURAERDECLARATION' °
1 hereby df3nm mat 1 nm eaempl from she Contrxme, License Law, for Nc
Following mown. (Section 7031.5, Business and Professions Code: Any city or coumy
which requires n permit to c6n3lmck alfa, improve, demolish, or repair any [aares e
prior to its issuance, also requires the applicant for such Permit In file a signed statement
Nat he I. licensed Wnuant m the provision of the Contactors License Law ICWI9
CONTRACTOR INFORMATION: PERMITNO.
'000 44 34
' SANTTARYNO, APPLICATION SUBMIT
NIC CON'LROL#
I IULDING PERMIT INFO
Job Description
' • . ,:NEW FoccR-GA2 GAR -AGE
y
Sq. Ft. F oor Area .g/�3Va�ion
_-- _•._._____......,.,,_ .........................r..... an. rrraesno.. iaoa as ..
that he is eaempl therefrom W me basis for the alleged aemPnon. A, wblad.n Of APN Number - Occ'u 1•Ine Type
Sondra ]031.5 by any applicant for a pamit.objau me applicant to a civil penalty of "'I /yf� U l Y yP
t more Nan five hundred dollars (S5M). - 3 to r 0 3' - 000 -
pkasonerofthe Prapent,°rmyenn"'On.wish w.ee.asmair sole eompematl°n, - oan -Required Inspections '
wdW m
ldo me work.e structure is not unscathed moremd fonde(Ser.7064,Bunus um -
and Prof e..iCode: The Comvaaor9 License law doe, not apply to an Owner of r
pr.PmY who build, or impmva Ihaaon, W who does such work himself a through own cmPloytted s, jmvidmal such impmvemenu tic not intended or oRemd for
We. If, hoeve, she building or improvement I. sold within one yeaof cuse,joi m. she
builder will hese the barmier of proving mat he did oro build or improve for parr- '
ouale.l.
owner of the property, am <aclusivaly cony Lang with licensed contractor to . .
.—let the project (Sac. 91361, B..imuc and Professions Code:) The Contractor, U.
centra Law does not. ply to an owner of propenY w W Wilda or impruva thereon, and .
` who contecm projas wimaconwetog0licenied punuanlmNe Conb.cmr[ (([�')jp -
License La
❑lumc mon r a. ,BffiP or Nis n
Owner Date V Q O L�
'
WORKERS C ffSATION DECLARATIONL
I hereby affirm under partly of pajuty oro of IW following dalnations:
�'.. ❑Ihe,a and will maintain acerbic.,ofCmc,mxb.injur, for Worker's Compen.
union, a Provided for by Sado. 37W of the Labor Code, for me p'fomuna of the
work for which this pmmit is issued.
❑ 1 have and will maintain Wmker, Cumpano tim Inemnce,. a required by Section
I 37W of the Labor Cal, for me penn
foance of me work for which this permit is issued.
My Workers Compcnution Insurance carrier W Policy number art:
Carrier: - Policy No, a
:CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mu,s,sain.read r'.t WcomplesedifOx K-11 is far... hundred dollars($IN)
or less) •p„,, _ � " "
I ccrtify lha in the reff..c.hhe work forwhicfithia Pamir I. Issued. I Sul
not employ any person in any manner so u to become subjrct'.the Wurkas' Concern. ' - -
anionLaws ofCalifornia .Issue _
Applicant
If,
NOTICEubj APPLICANT: es aha making this Cisions o ofExemption,Labordy.0 should
became subject tome Worker. Conrpenat i, Provisions b the Lehr Code you must
fonhwiN comply wish each prmvitlons.r ti, KrtniuWlihdttned revoked. k '
CONSTRUCTION LENDING AGENCY
Q I hereby inn dw mem is a construction leading agency for the Performance of '
Z meworkforwhichthispemritisiod, Sec.30t
•y 9], Civ. CJ
E" -
Iendre.Addr
m -
C4 > laanAmro:
d0 I certify met I have a Ild[ p tic - d state that the above inform.bon is
= z cora.(. I agree to comply wi I cit drdi., W ,are Laws ishoug to
building con.tmcd.m, and her y se pre mi colts city'. amerupom me
U alnve-mentioned Poo eny for .pocuo to res. +
v' F (We) agree m save, in de fy kap harmless the City of Cupartan against -
0 U 14bilitics,judgmcml, orace and aprnxs which matin say way. ante agdmst said City - n
,y WW in con=cquaxa of the ind ire of this permit. _
t� APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON PO -
U z SOURCE Rhou"A IONS. -
•—/%.
r 'Srgnam fAPPI canUComncbr .. Date `/ `9P- w.lJ C(i l'
HAZARDOUS MATERIALS DISCLOSURE '.
Will de applicant of faufe Wilding occupant some or handle haaWaus maxnd Re -roofs •'se
defined by the Cupertino Muni" pd Code, Chllef 9,12, and the Health and Safety - -t v
Cm, Sent. 25532'.)7 . Type of Roof
❑ Yei
Will the topical future Wilding Occupant use a9aipmemtordc„reawnirh All roofs shall be inspected prior to 5ny roofing material being `
=mit headoua air conuuninans craned by idea Bay Area, Air Quality Management installed. If a roof is installed'without first obtaining an inspection
I)iaVicl] .,
❑Y=a No I agree to remove all new, materials for inspection. Applicant
Ihavax ha °usmamndsre ar meat Me,Chefs,695°fheCai-Lunderstands and will comply with all non point source regulations.
roman H ay Code. Sauons 25505, 25533 and 25536.1 undestW Thu if Ne
Fuildin rely ha a rank merit ismy rc,Foradni' m notify mire acupanta' '
of the i iemeae of a dice seed
rhymer , .naed.entm _ — pplicantDa[e•' m- ..
All roof coverings,io be Class "B” or better '
OFFICE'