06030129BUILDING DIVISION PERMIT
MISAMI
I bercby of am Nat I am licensed under Provman of Chapter v (commcncmg
with Section 7000) ofDividon 3 of Ne Business and Prafevriumu Code, and my liceue is
I. full forte and effecL
License Clan Lie. a
Data Conuxmr,
ARCHfIECrS DECLARATION
1 understand my Plata shill Ito toed As public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby uTirm Net I am wempt (nm Ute CanlraCmra Lkeae law far tia
following name. (Section IID I.S. Business and Potassium Calc: Any city or county
which acquires a Permit to conmuca that. improves, demniLsh. or repair my gmetme
prior an its issuance. also equina Nc applianl for such permit at file a signed stslemcm
Net be is licensed pursuant to the provision of Ne Conuame, um= law (Chapter 9
(cmnmcncing with Section 7000) of Division 3 of the Bananas and Profession Code) ser
that he a except therefore and the bub for the alleged exemption Any violation of
Section 7031.3 by arty applicant fora permit subjects the aPPlicmt le a civil penalty of
not mon titin five funded dollan(SSW).
❑ 1, a owner of Itis property, or my employees with wages As them mk compewdon,
will do the work and lite structure h amt intended w offered for sale (Sec. 7044, Bumeas
and Pnfesdon Code: The Canvaanr's License law dos not apply N an owner of
property who hoildsalmpnows therms, and whodostachwork hireselfor through his
own employees. provided that arch Improvements ata not Intended oroRned foals If.
anwevar. the Wilding or improvement is sold within on year of completion. the owner.
builder will have the humen of proving due he did an, Wild At improve for purpose of
1, As aum r of Ne Property, am
team law does not apply m an owner of property who miles or Improves team
who contracts for nuts projects with a conmmmrts) licensed ponwnt of Lee COAL
Licence Lew.
nf.m e.em dlr see .B B PC rak this
A' thereby (look under penalty of perjury atm of the following dabnadon
1 ham and will ma r b in a tion 3este of Cones Code.
sum far Performance
Compere
waw, a provided fes mi Section 3700 of the labor Cotle, for the performeetce of Ne
wodc far which this permit is issued.
❑ 1 have and will maintain Workces Compensation Inwmnce, As mqulmd by Section
3700 of the Labor Cade, for Ne Performance of the work for which this permh is band.
My Worker's Compensation Insurance artier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section wed Amt uncompleted If the Peanut Is foronc hundred dollars (SIN)
or leu)
1 cenify met in the pelparnance of the work for which this permit is Issued. I shall not
NOTICE? ARE�JEARP.lf(nfter making Nb CemRate of Eacmptton, you mound
bttame m a m the Worker's Compenwlion provisions of the Labor Code, you moa
vJO forthwith comply with such provisions or Na permit hall be deemed mvnkcd.
zeeCONSTRUCTION LENDING AGENCY
(—A I hereby alarm that Nem a• construction lending agency for the performance of
GL
the work ror which this permit is Leaned (Sec. 3097, Civ. C.)
W Q Lattices Name
;D z Lenders Address
U Q 1 cenify that I have mad this application and stste Na the 1bOW information b
LL F correcL I agree m comply with all city and county remittances end Sum laws misting to
0 V Wilding construction. and hereby autho fe mpresenutives of Nis city to enter upon Ne
if] above-mwutmed property for inspection purposes
(We) agree to save, indemnify and kap harmless the City of Cupertino against
y liabiliticaphigmenu,cwts and espena, which may In my way¢arae against said City
U z in come uena of the getting of this permit.
^ APPLICANT)ADERSTANDB ApID WILL COMPLY WITH ALL NON -POINT
MATERIALS DISCLOSURE
ulding occupant gore or lundle hrumaw maarin
til Code. Chapter 9.11. and the Health and Safety
Ova, [3 No
Will the applicant or future Wilding Occupant an, equipment or devises which
vamow air canuminmts a defined by the Bay Area Air Quality ManagCMCM
Oyu 0 N
anent. that It b my responsibility to naury do
be ma prior.p issuance of a Ccsurcaa of ocm
6030129
PERMIT MUE UA IE
SANITARY NO. CONTROL NO.
Job Description
SFDWL DEMOLITION
Required Inspections
Issued by:
Re -roofs
Type of Roof
ensures rano" mro
Date
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.
Signature of Applicant Date
All roof coverings to be Class "B" or better