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BUILDING DIVISION PERMIT
T
LICENSED CONIRACIUR'S DECLARATION
I hereby afrtrm door 1 am liernvd under provisions of Cheptu 9 (c menerc)ng
with Section 700(y)of Division 3 of dee B...acts and Protected.. Code, and my bounce is
I. Poll fort `and.
liceve s `— 3
Dna �'�Contrxme �
ARCHITECTS DECLARAN
1 undersand my plas.hall W used as public records ,
OWNER -BUILDER DECLARATION
1 hcrcby sBiem Nat 1 am extmpr from the Comtecmre Lt. Lew fm the
following morn. (Section 7031.5, Bothersome and Profadom Code. My city or county
which requires a ISeumit in tantrum, altar. improve, demolish, or repair my snuemre
prior to its ismame, also rtquires the applicant fm much permit m file a sigrcd satamem
that he is licemrd Forecast an this Provisions of the Contractors Limns Law (Chapter 9
(commencing with Satirn 7000) of Division 3 ofthe Rumors and Proksaions Cde)or
that he is exempt demallo m esd the basis for the dkgd exemption. My soldw of
Section 7031.5 by any applicent for a pmMt subjects the applicant to a civil peaky of
a come Nan five buMrtd dollen fS5o0).
C I. a owrcr of tW property. or my employment with wages a their sole compensation,
will do Ne work will themoumre is nm tentative or offend for W. (S., 7044, Rod.
end ProrenewI Code: The Contractor's License law does wt apply m an wmer of
property wW builds er improv. drown, Send who don such work himself or dere
his awn employees, pmvidd tha such impro .. ere nm boarded or fmad fat
Sale. If, h..,, the building or impovemmt Is told within ow yearof eampletim, da
own-buiWn will have the burden a proven, that be did we WiW or improve for For.
Laws of We.).
C 1, a ownn of the property, an, reclusively contracting with licensed eanuannn to
cwmuct the project (Sec. 7040, Bmircss and Pmfeasba Cd,:) M Comactmi U.
canna law dos not apply in an owner of property who Wilde or improves thereon, and
who cow"Is, for such projau wide a conuamor(s) Ikened pursuant to the Contractors
License Lew.
C l core exempt under Sec. . B ge p C for this reason
Owner new
WORKER'S COMPENSATION DECLARATION
1 hertby sf neer undn Penalty of Perjury one of the following dxlanuom:
❑ 1 have end will maintain ecerti0cuc of Coasemto selGinsun forwodeafs Compen-
ation, as pmvidd for by Section 37W of the Labor Code, for tM perPomssvice of she
wok r(so ' pmmit is coast.vis end will Wisdom'sCompImunxe, nqid by Section
be Labor Codes. for the per.mConke often work few which this pennit Is luded.
My Wo
rt a�6w%i%�",-p�rtittrand Portyx72Z0542 6
Carrier: Policy O L
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CERTIFICATE PE SATIONIINN PROM WORKERS'
COMPENSATION INSURANCE
(this satin most on W cornptetd ifthepermit is fororohundrtddollen ($Iw)
me kuJ
I certify that in dee my regime er n as
work for which this thepermitis issud, l Shall
not employ any Canon in any manrcr w es to become mubjano the Workers' Compcn-
plawia
s of Califmm. OncApplicante
n
NOTICE
NOTICE TO APPLICANT: If, Cm mnsati Nis provisions
of Exemption.bord . y ahold
hxomc subjeel y iia Workers Compensation .I, ."It
of doe Labor Cde, yw most
foMwith comply with such provisions or this pemnit shell W domed cooked
CONSTRUCTION LENDDIG AGENCY
0 I he M. that then is a wreatmdon lendin, agency for Ne perks. of
N We work for which this permit is iaud (Ss. 3097, Civ. C.)
[� id Lendefm Name
(� lander. Address
{i) 1 cerdfy that I have need this application and state Out the above information is
0.0 woad. l ague to comply with all city and worry ordinances and man laws miming w
U O building canaWchory and hereby wasomla repreamWlves ofthis city aenm Ypoll the
aWsrmmtica d property fer inclined.. pompous.
W F ( We) Sierra be sive, indemnify and kap harmless the City of Cupertino against
t.i IIabibble,judgmeew cats and expaus whit yin ay way accrue eying aid City
>., {,� ireconte9ucreceof0a 6rundng of Nis
F gL
APPLICANT UNDERSTA COM TH ALL NON -POINT
V w1. S URCF RFC
sigaturt sir titan next Dna
H RDOUS MATERIALS DISCLOSURE
Will the applicator futon W ildint occupant emnm hWle haraMoa naterial
at dcfircd by the Cupertino MuNOpel Code, Chapter 9.12, Send hit HWth and Safety
Costs, Section R5532(a)? /
❑Yes W
Will the mplkat or futon W ildin, wconcern use m eynsm, or devices which
emit hazardous air conaminanu ao dell by hit Bay Arm Au Quality Management
Direkl7
C Yes
I have tend the hesardrwm commentsruluinmenu oder Chnpur 6.95 of the Cali.
tants Health @ Steely Cade. Sections 2 ML 25533 and 255N.1 understand that of rhe
WilEingdrcs nacutnmlyN eo it is my responsibility to ratify the recupent
of It ust t pre uses f S�df Occupexy.
Ownervthoiew aBcm - Dau
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Job Description
C
CONTROL,
Sq. Ft. Floor Area ., Valuation
e,`� C; 00. c;o .
/ APN Number Occupancy Type
Required Inspections -
f
r v
t
Type of Roof
A271/5—
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.
Signature of Applicant
OFFICE
All roof
Date
to be Class `B" or better