00030074BUILDING DIVISION PERMIT
OWNER'S
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LICENSED CONTRACTOR'S DECLARATION
1 hereby alErre Net 1 she licensed under provisions of Chapter 9 (commencing
wit Section 7") of Division 3 of to Business and Politicians Cade, and my fiance is
in full fora and effecln
ARCHITECTS DECLARATION
I undersWW my Plans "I W used u public records
Ucrrued Poressinitial
OWNER -111.31 1)11 ATION
I hereby effort tat 1 un eaempt from to Contractors Liame, Law for to
follovnag maws (Section 7031.3. Buries, and Professioru Cade: Any city or ooumy
which nephew a permit to emetrtxL .Iso. improve, demolish, or mMis any smcnm
prim to i4 issuana, dor es,mis the applicant I ...ch permit an file a.ignrd r4aeram
Net he is licensed purausm to to Provisions of the Contrxmre Lianas Lew (Chapter 9
(commencing it Section 7000) of Division 3 of the Business and Professimu Cade) or
that he Is esempt therefrom and the bore for to alleged emmption. Any violation of
Section 7031.5 by any appmet, fm a Perot ubjects to applicant to a civil penalty of
t mom tan rive hundred dollars 13500).
I, as owmr of to property. or my employees with wages as debacle ..No .,
will do to wake and tori ucNtt is .1 intended or Offered for We (Sae. 7D74, BualMrr
and P nfessiom Code: The Contractor. Lioerue law does not apply w an owner a
property who Kilda or improver Leucon, and who does each work himself or trough
his own employ.,. Provided died ruck in,ameacreenu me not intended or .Hared for
We. If, however, to Wilding or improvement 4 sold whin ora yeasofconWiedon, the
owxrWiMm will haw de burden of proving tat he did rust Wild or improve for per,
pee of Wo.).
I, as owner of de property. am exclusively cmbec0ng wit Ikenred co mmm to
construct to project is.. 70,14, Business mc! Proteatbns Cade:) The Contrecue. LI-
cene law alas ant apply to so owni of proputy who Wilds or improvee, terem, and
who conmants for such projccu wit acontractrat licenced Wnuant in to Contecmr.
U.nm law.
ofemeaemptade,See. B&PCfor tisMason
owner Dao
WORKER'S COMPENSATION DECIARATTON
. 1 hereby affirm on
m under pno0ty of perjury e of to following di durations:
❑ I he. and will rmlaw. s Cenificate ofcament to.If.m. forworone.compen-
ution, as provided for by Section 3700 of tW LeWr Calc. for the performance of the
work for which tis permit is tamed.
❑ I have ad will maintain Wmkcrs Compensation Insurance. as required! by Section
37Wofte poi Code. forte padium iev ofte wookffarwhich E this permit 7pe�mrit is ismed.
Ca ems' ` do nwr c cnrrlaPolirYNoeuZfN 3n
CERTIFICATE P EXEMPTION FROM W S'/
COMPENSATION INSURANCE 3
('ibis section nand not becomplatd iftc permit is foro.h ue(31W)
or lar.)
I ectify the in to performance ofte work for which this permit is issued, l shall
rust employ any person in any mannar so at to become subject as the Woakma' Cooper.
..tion taws of California. Due
Applicant
NOTICE TO APPLICANT: If, after making tie Certificate of Exemption, you should
become subject to to Workers Compensation provisions of me labor Cdr you must
forthwith comply with such provisions or this Permit shall W dimmed nw.kd.
CONSTRUCTION LENDING AGENCY
M
O 0 1eby aRnndathem em is a,.mm lading.geey for Oe Performance of
Z u to woh for whin tie permit is issued (S.. 3097. Civ, C.)
I: handers Name
ori faders Adduces
=7 1 certify that 1 have red ter ri liation and.tate tet to above information it
ficoA correct, l agree incomply wit ell city and county momenta. . and.4m ng lawe reldass
7 z Wilding construction, and hereby atuemito,.Pmarnwiv. of tis city to enter upon the
U O .Wve.memiwd property for inspection purp e.. -
kr �. (We) agree an save, indemnify and keep harmless the City of Cupertino against
Q („)
liabilities, counts and eapnun which may in any w.y.ame... 1. Wild City
in
ncontrast a of to granting of ti, permit..
ow APPLICANT'UNDrRMI'ANDSANDWII.LCOMPI.YWITIIALI.NON-MINI'
U SOURCEREGULATIONS.
SignamreofAmlicanticomector Due
HAZARDOUS MATERIAIS DISCLOSURE
Will the applicant or fugue Wilding ncctipm atme or handle bound., mammal
as defined by the Cupertino Municipal Code, Chapter. 9.12, real the Heap and Safety
Code, Section 215324)7 ,
❑^
Yes / AND
Well ft applicant or It. While, acupent ... ... ipmem or device which
emit harardous eE cunumimnu as defmd by to Bay Ares AG Quality Management
District?
C] Y's
1 have mad the herudo., numiala capiemrn4 uoder Chapter 6.95 of the Cali.
ramie Realm At Safety Code, Sections 255(y5, 25533 and 2553.. I utNntW tet if to
Wilding does uo correctly have a accord, tan it is my responsibility in nmJy to occupant
of the, regturemem which mus be met Prior to issuance of a Certificate of Occuyency.
Ouver,mandemund.gem Data
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1 Job Description
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Sq. Ft. Floor Area Valuation
1 APN Number Occupancy Type
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MAR 1 0 2000 D
4l3eg5
Re -roofs
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 aggrs andree to remove all new materials for inspection. Applicant
undes and will comply with all non point source regulations.
-z'0Jo
Signature of Applicant Q D to
OFFICE.
All roof coverings to be Class "B" or better