00040061BUILDING DIVISION.
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Z a. N LILRNSED CONTRACTOR'S DECLARATION
O OZ — ❑ 1 heebY aRvm Net 1 em licensed adv Provisions of Chapter 9 (wmmenciag
rLt J with Sermon]000)of Division3 of the Businenad Rofeuions Cade. midmY littnm is
in foil forced effect.
License Cissa - U, N
3 a y Dart Conuacmr
ARCliff=S DECLARATION"
y I Louis. I shall be u u public ecoids
°• �. o Llcenad Professio .
OWNER -BUILDER D RATION
t'Z < 1 bertby Rco that 1 em exempt from a Comracmh License law for the
D . following reason. (Section 7031.5, Business and Pacification, Cada: Any cit, or at,
+' which im,dres n permit in construct; ager, improve, demolish, or, reptor any structure
prim to its issuance, also "area We Wficam for such permit to rile a signed alatetnem
that M is formed pu.us. m for provision, of the Coneutora License law (CTaptm 9
(commermag with Section 1000) of Division 3 of We Business and Profession Cedc)or
that he Is exempt therefrom and the hssis for the alleged come sim. Any violation Of
Section 70315 by any applicant for a permit subjects dere applicant to a civil penlry of
nor come mann Eve humbd dollars (550)).
Las owner ofthe property, or my employees with wages an their sole compensation,
wdl do the wort, said ha esso mre I,.. intended m oReed for We (Sm. 70,I4.1hasom s
ad Pmfeuions Code: The Conummrs License law does not apply to an owner of
property who builds or improves Warton, ad who does such work himself or through
his Own employees. provided that such improvements cure nor Intended M offend for
We. If, however the holding or Improvement is within one ymrofcconpation, the
r -W ildm will have We burden of proving that he did no, m par
-
P
improve for p-
pooe�f We.).
h en owner of We property, em exclusively convecting with licensed contnnon to
construct the project (Sec. 1044, Bmimes ad Professions Cde:) The Convector's u.
.. Law time Out apply to an own. of property Who holds or improves mM on, and
who concocts for such pmjma with a conmwdo fa) licensed pursuant to to Contncbls
License law.
❑ I .n eumpt sea&, S , B & P C Nitride reason
r Owner m"I Date
`O✓ORKER'S COMPENSATION EC.f.DowON
I hereby md.dfirm under pemWry of perjury o of Ne following dmlmetio o
son, as and will rtuintainaCmiflcuc ofC neer Code,
forWodeM1.ofthe
wuion. M provided fPe mi Section 3]00 of dte ams Code, for to perfomanca of W
work fm which this permit is issued.
❑ 1 have will NCompers swd by S.fion
ofWeLabor Code, maWispadsmeaidewords for which his permit is issued.My
Carrier:
s Compensation Insururce cam. and Port:
lley number a
Ca
Cartier Policy No: r
CERTIFICATECOMPENSATION
FROM WORKERS' '
COMPENSATION INSURA NCE
(Thin tecdon neednrot becompletd ifthe parrot is foronhudrd dollen (5100)
Of lta6.) '
I tend, that in thepnfomeme of Ne workfor which this permit 4leaded.I rbdl
ant employ any penan in any manner ... to became wbj., a the WantonCompcn-
mnon laws of califomlc Date
Applicant
NOTICE TO APPLICANT: IL after malting this Certificate of Exemption, you andld
hecome mbjrm to the Workers Compensation provisions of the laws Cade• you must
forthwith comply with such provisions or this pemmitshall be demand noted.
m
CONSTRUCTION LENDING AGENCY
0 0 I hereby affirm that Wert iso conscocdot lending agency for the performance of
Zthe work fm Permit which this peit is issuedec
(S. 3091, Civ. C.)
lander, Name
CC 7 lander, Address
W 0 1 nertify that I hove nod Wis epplicuion ad mute that the move ididmution is
0.correct. l agrm to comply with all city ad d county ordinances anate laws elating to
��• z Wildingcomvucturt. end lymtiy outhonisi representatives of this city to enter upon the
t.i move -mannan d property, for inspection purposes.
(We) agree in seve, indemnify and keep harmlw Ne City of Cupertino against
V lishiliti.,judgments, core ad espenxa which may in my way areae against said City
,m W in consequence of the granting of this permit. r
E•m C6 APPLICANT UNDERSTANDS AND WI LCOMPLYWII'HALLNON-POINT
V Z SOURCI?Rr:GV�,�S"I'IONS.1 �,
IN I
SANITARYNO. APPLICATION SUBMITTAL DATE
NIC CONTROL#
Job Description
//eA�/ /3,4`7' L4,/)
rv✓J 9 w
AFN jVumbe
7— 2s—oY6
46/
00
B
OFFICE
y
O �� {'�%/.,idVk.�[(.. n ,
Signmre of Applj anUConvecmm Data
HAZARDOUS MATERIALS DISCLOSURE
V//
"A" applicantorfrnurtWildingvcculnnmmnnmhadlehazaouemamritl
Re -roots
m defined Is the Cupertim Municipal Colo, Chapter 9.12, ad the Health end Safety
Cade, Section 25532dr -
Type of Roof
❑Y.
will the applicant or future Wilding occupant use equipment ofdeviis, which
All roofs shall be inspected prior to any roofing material being
Faada b=an.nin. a,deFn dFYW Bay Area AbQuality M.mg m ret
installed. If a roof is Installed without first obtaining an inspection
❑Yes
I agree to remove all new materials for inspection. Applicant
I have read the Lanrdous materials mquir mens udcr Chapter 6.95 of the Cali-
Un erstands and will comply with all non point source regulations.
Name Health & Safety Cole, Sodom 25503, 25533 red 25530.1 understand Wal if the
Fuilding does ndc mIY vicemnant et it is my eapomibiliry mnrotifY rhe ttcupani
'•' -
'
fine requ'vcn en , must NeCTr w iseuenee C.dfim of Qcupmcy.
Signature of Applicant - Date ,
OwnermamhoA wage., Date
All roof coverings to be Class "B" or better
OFFICE