00040006CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
LICENSED CONTRACTOR'S DECLARATION
1 hereby amrre Nal 1 sm licensed under provisions of Chapter 9 (commencing
wall Station]Opo)ofDivision3of Ne Businnsand Pmfeuiom Code, W mYliccmeis
in full twee and )T /
Iicemt Sliy � � �JO Conti
Due_./[-�' Contractor
ARCHI'TECPS DECLARATION ARATION
1 nndemtand my issue awl he neea u wbliC rants.
Licensed professional
OWNER -BUILDER DECLARATION
1 hereby aTo. Nat 1 sm exempt from the Conrracmh License law, for the
following raison. (Section 7031.5. Business and Pmfevions Code: Any city or county
which mquires a permit in comtruct alter, improve, demolish, or minor any structure
prior to its issuance, also minims the applicant for such pemdt m File a signed comment
that he is Ilcemrd p rmsen to the provisiom of the Comacton License taw (Chapter9
(commenting with Section ]000) of Division 3 of the Business and limitations Cod.) or
that he is tempt therefrom and dte basis for me sllaged exemption, Any violation of
Section 7031.5 by any applicant fora permit mioncor on, applicant to n civil penalty of
not more Nen five hundred dollen (S50o).
11 as owns of the prope v. or my employees with wages n their sola compewGan.
will do its. work, and the swdurc is nor intended on offend for ,,iso , ]000, Basins.
and Dotes o -or Code: The Courteous License law does not apply to an owner of
Perf""y who builds to impoves sherma, and wed does such work Itimulf or tsrough
his own employees. pnv;ded Nat such improvemuus art not intended in offered for
sal.. If, however the building m impovemem is sold within one yearcd.m tplafim, the
mitenW dder will have the burden of provost that he did nut build or improve for pur-
pose of a fl f
1, am owner of the property. en..Clusimly contracting wish licensed comma on m
construct the project (Sec. ]004, Business and Profession, Code:) The Camaztw'e Li-
cense taw does not apply to m owner of popery who builds or improves Merton, and
who conmets for such projects wits a coronations) licensed pusumt in the Cumecorm
License law.
I am exempt under Sec. ,B&PC for this mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
• 1 hereby alarm unMpenaby of pe tory one of Ne following decleatiow:
❑ 1 have and will maintain a trim 3700 of Comcm m so e.fort for efform ecompen-
w rk f as provided for re Sadon 3]00 of the labor Cade. for the penwnanee of the
wort for which this pentd, is issued.
1 have and will maintain worrier. Compenortim Imurence. as mr.00d by section
. ]W cf Ne LsborCMe, fur Ne performance mthe work for which this permit is issued.
My Worl, mpmoah l lnmrgnce cam .orand Policynumber p J any
Cartier_Tn%a_i��,glAs, 4Finis/ Policy No.:���y LQ dT•) R/
C �RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ssci m need not W mmpleud;ftie patiot;s for one hundreddollum (5100)
or less.)
1 certify that in the performerce ofthe work for which this permit is issued, I awl
not employ any person in my mine so to We bjauo the Workers' Compen-
vation laws of G¢Iifomia. oil O 'fl
Apphisom /! W IIIc i ,p.IYA
NOTICE TO ,C LICANT: If, after 0 is Cmifmae of Exemption, you mould
become subject to the Workers Compensation provisions of Ne Latur Code, you must
fordwoh comply woo such provisions or this panni, swl W dammed revoked.
CONSTRUCTION LENDING AGENCY
Q 0 Thereby affirm Ne dm iis a comtructim lending agency forthe puformmce of
w�. Ne work for which this permit is issued (Sec. 3097, Cr, C.)
F., Landers Nana
> Lander, Address
W 0 1 candy that 1 have read this application and stem that the above information is
0.correct I agree to comply with ell city and county ordinances and rule laws relating m
U 0 building conawction. mJ hereby au,hwiss rtpreaaWivee of Nis citymmmrupon the
above.menumsed popery for irupeNan purposes.
Ia. F`„ (We) agree to rave. indemnify and kap harmless she City of Cupertino agvmt
C C.) liabilities,judgments, tomo and expense which may in my way mcme against said City
>, LTi in comequcae of the granting of Ibis permit.
F_ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT
SOURCE REGULATIONS.
4 AA /170, 4'vwe E IFAle-
SAti,r�t- �. 9.liPr:s
Sq. Ft. Floor
S6 -
Sig. ifApphcmtfCmtraenr Dau f
HAZARDOUS MATERIALS DISCLOSURE
Will Nmpplinn, or future Wilding Occupant sort or has harudous menu roofs
,R defined by the Cupertino Municipal Code, Chapter 9.11, and tse HWN and Safety
Code, section 8531(a)T Type of Roof
❑Yes No
Will Ne applicant or future building occupant use equipment or devices which
smut he ardms our contamirmnts as defiled by the Bay Area An QW iry Mmegcmcnt
0Dim ict]
. [3 Yet FlNo
I have sad rhe nuardms maW;sls equiemmu under Chapter 695 of rhe Cali-
foms Health & Safety Cade. Sections 25505, 25533 end ]5534.1 understand dons if the
building dons nil currently have a tenant, that it is my esponsibilitt m notify the occupant
of th c t which must he con prior m iemanea of a Cmif, �e of Occupaney.
red ages - 9l�'
Job Description
000q VV C71
NAC
G �. os'
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