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BUILDING DIVISION PERMIT
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' LICENSED CONTRACTOR'S DECLARATION
I bereby affnm that T ren fthe Bu under provisiom of s Coda, 9 (commenting ���e� J�Ib Descri tip on - /` 7V , /.mss. /
with iefollfoSection 7o00flect. ision3ofNe BusiwraN profeaai.a Code, and my Bcensei. 'T /Ci!//� f/� l� ,Y /YY/YV
Dense Clan uc.N�T�
Date Com
ARCHITECTS DEC DECLNIATION
Iy "round! my Plane sh Ar-1uNbIS ossa/,i1�a/ -
f OWNER-BUR.DER DECLARATION
1 hereby affirm d. I am sump from the Cremaster. Lt.. law for the
following meson. (Satim TOILS, Bonuses and Profaaioe Cade: My city on..my
which renuLes a Pvmit no I.i, alter, impmvs, demolim. or rtPat, any ..clam
prim to its iuoea. also requires the applicant torah Permit to fit e a slgrand.atemem
that he is licensed puremad to the provisions of the Contractors Lt.. Uw (Chap., 9
on .cin, with Section?111)(18 of Division 3 of the B.sincss send Pmfmima Code)or
Nat he is exempt th.ef .. and the buts for the allegW ..prion. My victim. of
Secton 7031.5 by my applicant for a permit ubjects to applicant to a civil Penalty of
not mom Nm five hundred dollen (f50o1.
tPt 1, a owner of the property, car my employee with wages a their .1, caensa
mpton,
Jl do the work, and thesuunure is our intended or offered for We (So .7044, Baume
anal Bofeasiom Codi: The Contractors Lic.me Law w dunm apply to an owner a
Property who builds or improves thereon, and who does such work himself or through
for own employees, provided met such melmovetnena aR no intended m offered for
-ales If. museva,
the building or improvement I, mold within one yearof.mi,lo i m, rhe
r -builder will have the bmden of mvi, Nu he did.t Wild or improve for pur-
poseof.de.).
D 1, as owner of Ne Property, son culuuvelY comnsctng with Ihxnsed eonoamon an
co muct the Project (Sm 7044, Bummer and pmfeWom Code:) TM Commuters u.
c.a law dines tapply be an own. of pr arty wW builds m mmovm thereon, med
whe conte.. formch Projects with a contactor(.) licensed moment b use Cmdooncrs
UL.. law.
D 1 sm ppot meds, Sec. —if --/ .B9�r ort1ie maa h
1 hereby aRrm motherp.W, of Mjury oa aIle following declarmom:
1 have and will meinuie. C 'kswc of Cemento, self-insertfor WoheesCooper.
li., u provided for by Section 3700 of the tabor Code, for the porformance of the
ork for which Nis pound, is issued.
D 1 have and will maintain Wmkces Compensation Insusame, Is, required by Section
Mynd. the LaWrCade, /or lNrte pmfortname o(nc� work for hich this pc.il, issued.
MY WorkerV m'c"" %nra'c p "s"
Cemee_ s,L—
CERffFlCAOE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nor u. need not be.mpteted J Nc Permit is far oe huMred dollen (f 100)
or len.)
1 certify pe in lin my manner ofthe work for whichthisto don W is issued I shall
rot employ of Penor in my manner w m to become sublat to Ile Wortrn' Campen-
uhion Laws of California. Date
ic
ret
NOTI
NOTICE TO ci W the Workers
If, after peeking Nis CenlBate of listened.,od . y umulst
bechwith jai y the Workers Compensation forms
hal of to Ubu, Code, you must
forthwith comply with such provisions or Nis permid.hall h deemed rooked.
CONSTRUCTION LENDING AGENCY
Q Ihereby affirm the Nem is a construction lending egmg for the Performance
Z�w a to work for which this permit is issued (Sa. 3097, Civ. C.)
r.r 4 Under. Name
[(� h7 L mdee.Addne.
titI unify Nm 1 have road ed Nthe this application sarae at above W omtui. is
L z creat. l Igree a mmp1Y with cal city and my mclimmo,; end... law. n:INng m
.�. z building c.s.salon. end hereby mmodw tepreseutves of this city to enter upon the
U O gbevetn.t.cd pmperty for impaction or,mem
(We) apse in save, indemnify and kap homeless the City of Cupertino against
0 V liabilites,judgm.a. coxa and..pence. which may in an, war e.aeguml said City
in consequcoce of the grmtng of this Permit.
F Fa APPLICANT UNDERSTANDS AND WILL COMP LY WITH ALL NONdYOINT
� g t'E RF.GULATI '
Sdgmmn A,,hcm90m=mr T-1 Due
HAZARDOUS MATERIALS DISCLOSURE
Will the oppkam orm. Wilding acupem It.. or handle hmeNous mal.id
as dcfiend by the Cupcnim Municipal Cade. Cinque 9.12, and Ne Heath and Safety
-Code, Section 25532(.)7
[I Y. PkNa
Will the epplicmt or forme building occ on use equipment or dcvicm which
em, haaudom w comenmena as darted by the Ray Arne An OW by Mrmgment
mac'?
Dyes �o
I hive reed Ne hgratduu. material' tequitem.ts under Chapter 6.95 of the Cob.
bmilia HWIh & curre Cede. Sectmand. 03i 23577 eed 25576.1 mdentmd that R the
Wilding d«a ma currently tenet, ttthyygttt the my mpoaiMlirymno,fY theaaupmt
of lM1�idW r. whichen m.pr fwy'yye�ye.c�rB�ore of Oc.prcy.
�//`JCI nun
Wn�X• agent Due
Sq. FL Floor Area
Valuation
Type of Roof
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
I agnea to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of Applicant Date
All roof coverings to be Class `B'r or
OFFICE