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BUILDING DIVISION,v PERMIT
BUILDING ADDRESS:
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LICENSED CONTRACTOR'S DECLARATION
i hereby +rcmn that 1 sA liccnsnd under pmviaimi of Chapter 9 (u
with Sation]000) ofDiviaimn3 of do Budasaemd Rofmioas Cate, W m
in full force and eRut. _
LJmna a
Date GOntnaml
Ae"Hi CI'SDECblie. ON ,0ij—(
1 understand my puts shall W mad u public rtcmds
Licen ed professional
OWNER-BMDER DECLARATION
1 hereby affirm Chet 1 an exempt from we Connacsoes License Law for the
following reason. (Section MIS, Be.[., red Profexiioes Code: Any city or taunt,
which Sept. a mnil to cartsRmL tires, improve• dcmoliA. or npab any abHmun
prim m its known.. also man., the applicant for sash found, m rile a signed adusi n
that he is burned formal to the provisions of the Cordowara Licence Lew (CNpsu9
(commencing with Smile. 700D) of Division 3 of the B.d. and Rofaaions Code) or
Nat he is cattle therefrom and de basis for do alleged exemption. Any violaon of
Section ]031.5 by Say applicant rm a pemdr abjects the applicat to a civil penalty of
ned nine them Ove hundred dollen (5300).
❑ I,asownu of the propenY•or my employees with wegesastMinolc cempeneatien,
will do Ne work, end the sVYmure is at headed or offered for eale(See 7014, Boineu
end Penfeasiam Code: The Convactmi lianas law closer mat napply tom nexam of
properly who bolds or improves Ncmon, and who does such work himself or through
his own employees, provided that such improvements are a, inteded or offered for
Sale. If, however, she Wilding or improvement ie Sold within a wyear of calendar. the
owner -builder will have the Wden of proving that he did at Wild or improve for 1,
pose of We.).
Cl 1, as owrce of the property, son exclusively cmbumng wish liunrd cenuacnrs to
container the project (Sec. 7014, Business and professions Code:) The Cenermar a Li-
cence Lew doer an apply to em owner of property who Wilds in improves thereon, ad
who contracts fm Toch project with acenRanm(a) limned pursuant to the Conommrs
License law. •
❑ 1 un eampt under Sea. . B & P C for Nis mann
Own. Dam
WORKER'S COMPENSATION DEMRA7ION
Ihadwill remundo p.rslry , perjurymeo selfinamengdalut'g Co
1 havead will mainlLn a GMiRt01e o(CONMI IO self-InaaR fol Wmkeraeampen-
tion. es provided (o by Sudors 3]00 of the labor Code, for tut pemormance of the
❑ 1 have red will maintain Workah Compensation Immomee. se nquiud by Station
3]OOaf rhe IaWr Code, IaPthe pufomuue o(she woh fmwhkh Nis permit b isa nd.
My Worker Com casa'en numec curia ad Policy nwAbe WpJ # / Z
Ceder: Policy No.: 5 /V
C • EXEMPr10FROM WORKERS'
1'NSATION INSN URANCE
(]Tis ncdM need not W <omplerd if rTe permit it foronehuntrd dollen (3100)
or leas.)
1 unify that in she any
afthe
as to
which this thepommil is issued,lshall
not employ my partum in any manor w as to become aubjus to the Worken'Compcn-
ation Taws of California. Dan
am
NOTICE
NDITCE ID APPLICANT: If. Cott making this Cumanof m Exemption, yen ahmst
bamm h comp to it shatters Compenuden provit hal of Ne labor Code, yin most
forthwith comely with each provisions or this permit shall W d«med mvokd. ,
CONSTRUCTION LENDING AGENCY
Q Iherebyalfitamesdrertiaaconnnake. lending agency for the perfmmemce of
Z ISI Ne work Be which this petmi` u isad(See 3097, Civ. C.)
Lad
y era Name . 1 / A
a Landes Addme —
W 1 unify that 1 have tad this application and Bute that the above information is
0. corral.
) agae m comply with W cit, andCanaryliva cnry estimates ad ams laws muting to
A Z building mosuucuon, end hereby adroou iramm ns ofthis city on enterupon Ne
C.7 Q above•mentioned property for inspection purymeno
(We) agree to San, indemnify sod kap harmless the City of Calamine Agalmt
Q rj lobilitiu, jodBex am more ed caperten which may in any way a croeagalmt Said City
>a Tai in consequence of the grouting of this permit.
wFi y APPLICANT UNDERSTANDS AND WILL COMPLY.WITH AU. NUN -POINT
V
SOURCE H IATIONS
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SrguurtofAphcCiceDu
HRDOUSMATER SDISCLOSURE
Will tie applicant or forum Wilding munition. or hudle Mrudoua ma amid
as dofrnnd by the Cupertino Municipal Cale. Chapter 9.12• and the Heah and Safety
Code, Smien 23532(.)]
0Yes nNo
Will he applicant or forum building occupant are equipment or devices which
an hevdoua air matermanta as defend by the Bay Ares Ah Quality Monogamist
istdn7 '
❑Yes ❑No
1 have mad tut haruduus mav'sli ox, immenm under Chapter 6.95 of the Cdi-
fomia Health & Safety Code. Sedan 25505, 25533 and 23530.1 mdMtand that if She
building due not curmmly Ma a seven. that it is my msponsibility in auify the u lfwas
of the on minatmta which most W mm poor to ismance of a CMiricam of Occupancy.
Owner or Summand agent Due
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Job Description
�O',\erL (Le��ocecvL��.1
Qc�\a _SSIU"1Le i n YL\VI A
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Re-roofs
Type of Roof
C
BUSINESS
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REOUIR
All roofs shall be inspected prior to any roofing, material being
installed. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
- 1/ 6 -- 3-z l -ono
Signature of Applicant Date
All roof coverings to be Class "B" or better
OFFICE