00040186CTTY OF CUPERTINO
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BUILDINGDIVISION'' PERMIT'
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LICENSED CONTRACTOR S DECLARATION
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Ihertby .Hirm that l am lipmeed under provisions of Chapter 9 Nximmeneing
Job Description ..
wish Section V00DofDi ision 3 ofthe Businasand Protasion Code, arta my license is
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infull fa deRfgyq.�L
License Cl l•'i-J o Lic.«.
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Data a 67-7 Conrrecwr
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ARCHITECT'S DECLARATION
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1 understand my plans shall be used as public ttwrds
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Licensed professional
OW NER-BUILDER DECLARATION
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I Withy tl111m+ that I inn a empt from the Comic,, s'1: cense Law for the
foil g a (Sou 9031.5 B mesrand0 fesswns Cade Any city ormanty
:-Ft. FIOOr'Area
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which res.yum permit m urn surer, improve, damoMn pal enY'rhucmrc
priori t ounce, alsonqu ate applicant I....chpirmnmfl .signed atetcmmm
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that he is liceiued pursuant to the Provisions of the, ConuototsLanse Law (Chapter
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'(m...mg win Section 9000) of Division 3 ofde Business ane Profm.ioi
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Nat he is exempts therefrom arM the basis for to alleged exemption. Any v
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Semon 9031.5 by any snubs. fm a pemut objects the applicant m a civil
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not mom Iran five hundred dollen (350).
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❑I,eiownerofshepropenymmyemployeeswirwagcsmdmirnolccom
will do the work and Ne structure is nes intended m offered for age Sec. 9044
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Coco The Contractor's License Iso does is apply lf
pro erty who s
progeny who builds or improves thereon, it who does roam work
or throughhis
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own employees, deed in
s ate not intended offered for
provided that Dave impimprovement is
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ild. ill hMildingmen of prmengitat he at rimprole far
owncobuildtt will have dre burden of proving that M did Ira Mild or improve for par-
pose of when.
❑Ler owner of Property exclusivelyad connecting aid licensed
ocontractor; on's.'
rnimd, project (Sec.. Business and
ct , B s Code:) TM Cmtramm'e
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case Low dress nut apply to en owns of pmpeny LAM Milds or improves Centro end
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contracts proecan mmrf
wnaan jwiaconcs)licenced pursuenuo Ne Conmcofs
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❑Rem exempt under Su. ,B&PCfar this rias n
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'WORKER'S COMPENSATION DECLARATION'
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tlf-insowingaerker's
W.aCrnWYofofCommiw
(havearm,ide main mi nation
ofConrnua self -in sum for Worktt'acem
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tion, as 37M he
the (pe by Section Lahr Cede, for the performance of d.
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Ihavwh¢hdiespemnrsissued
I have rola Section
maintain Wmarfa
requiredprm
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ofre Labor Code Poe reperoe meareACompethe A kfar whince.ch
ofthework for wbmh N's permit I, issued.
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Carder�espficY No.: �V
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CERTIFl A OF EKEMFTION FROM ORKFRS' ,.
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COMPENSATION INSURANCE I
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(Thi. were nod nm be crmplesedifre peramis forone huMred dollen (3100)
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or less.)
IcenifY Net in Neperfominceofthewoh forwhich this perMtis ia¢uad, (shell
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not employ any person in any manner so n to become object to Ire Workers' Compen-
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nation Laws of Cahifornia. Data
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Applicant
NOTICE TO APPLICANT: If, afmr making this Cer ificem of Exemption, you should
become subject to she Worker's Compensation provisions of the Labor Code, you most
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forthwith comply wish such provisions or His pc.I, shall be doomed rooked.
CONSTRUCTION LENDING AGENCY
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IMreby affirm that Nem is a constructionlending agency for the performance, of
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the ink for which this Permitissued (Sec 3099 Col. C.)
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Unders Name
lsnder's Address
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' 1 certify that 1 have reed this application and suite Nat Ne above information is
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4+correct.
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I agree to comply with all city and nd county Ordinances aspur laws telanng an
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building conswedon, and hereby ..Mile. presenasives of Mscity Nenrervpunthe
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above-mentioned popery, for inspection purposes.
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(We) a8em save, indemnify and Inasp harmless the City of Cupertino against
li.b'f.wquincofnecoca aoaoxpenees which may inoy way acciue egunr said City
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NT UNDERSTANDS WILL.
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APP. 'EREGUL ERS'1'ANUS AND WILL COMPLY WITH ALL NON -POINT
5 RCB REGULATIONS.
Sigr sec of Applican iCouunctor ' Data
HAZARDOUS MATERIALS DISCLOSURE
Re -roof$"+
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. Will Ne applicant of form building occupant store or handle intend ... material
ax defined by ted Cupenino Municiprl Cade, CMpw 9.12, and ate HesIN ane Sefcty
Code, Section 25532Rd? '•
Type of Roof +:..
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Will ted applicant or future Wilding occultism a;e equipment' or devices w�;ah
`All roofs shall be inspected prior to anyy'roofin material being
emit hamotha. air contaminants as dented by the Bay Arca Air Quality Manegemem
installed. -If a roof is installed. without first obtaining anrinspeetion
Din"`moves ONo .,.. - - - ' :•
I agree to remove all new materials for inspection: Applicant
is
basic meth the Mo dwa mereri a mqunemeauM5Chprer6.95terdmCali.
understands and will Com 1�/ with all non point source repula ions.
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eelr & safnY.Cade, Sections 23ws. 25633 Ona 25534. I uneersuind Net if Omdoes
rildingnes currently have a tenant, them it is my ma'an'doiny m notify dre occupantuucrncma
which most M nin prioi su issuance of a Cmfiam rf Occupemy:
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SignafureofApplicant ..Date'
wneroreuthoriz .gem Oam
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All roof coverings io be Class "B" or better
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