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NO PERMIT NUMBER CITY OF c DPESSIONNO CONTRACTOR INFORMATION: PERMIT NO. PERMIT BUILDING ADDRESS: NO. M1KNf@MbffrTALDKn DR owN� ii �, N,m6Y) T LIA� O"tW( ff ,�,}L ytJiJ(1-1 �11V11`^/y1/,•I.µIC''J� QOU DN/C G° ARCHITECT/F.NGINEER - � pULDING PERh/1T INFO Z O y "-) LICENSED CONTRACT'OR'S DECLARATION ' L hereby aRren Nat 1 am licensed under provisions of Chapter 9 commencin O Z-o ( $ Job Description P4C withS«tncoari 0)ofDivisi Sof the Bueineuand Prof yCodc, liana is ay Liters, "-55 G " DI RE—PIPE d0 U I-¢en6t teed k� L�/� yy Deu Convector n /1 1 )_'�n I� 1 gP/v1y/1/J�n' O As"I W use DECLARATION W Y 1ty{vq` (�t�(v/ v�y, 1 understand my Plans shall W used u Public records , 6f dCoo Limited ProfeWmal - u�='y OWNER-BUILDER DECLARATION - C?Q I hereby sfErm that 1 am exempt from she Convectors License Law for the ' C following mason.(Section 7031.5,Business and Pmkviom Cade:Any city or county ' m which RgWleane.sheretumsthealUc.improve,tforsuhperittsh,nrrasigany tWRent S Ft. Floor Area pdonolmlensedpulsom'.the thovisiosoffor Ceh Permit NfileeaLw(atabmem LI' $2000 thatmmehe ri ting i pursuance the of Disfonaof Ne eBusinesa License Won.Codtv9 (commencing with Samson]00p)of Division 3 ofthe Business and AvfeeaionaCnde)or that he is exempt therefrom and the Buis for the alleged exemption.Any violation of a�AYl Np er Occupaficy Type Section]031.5 by any applicant for a parent, the applicam to a civil penalty of J a not mem than rove hundred dollars($500). ❑I,as owner ofthe property,or my employees with wages an their sole compensation, Requirea Inspections will do Ne work,std tiw svucture is nm imrnded proffered fm eele(Sec.]664,Budrrtts and Pmfmdons Cede:The Concactori Li«nse Law it..nm apply to ae cant,of property who buildsor improv.Mrt eosu n.and who does ch work himself or Nmugh 202 — UNDERFLOOR PLUMBING his own<mployeet,provided Nat such improvements are not imendal m oRered for 3Q t Rt�-/t�(!�G UMR I ' 'We.ILhowever.dIhave dingorau of prism IssoldI within me Wildon of improve for .7iia� ENERGY ewner-builder will have Nc burden of proving that he did not Wild or improve for par- : F L . . pose of sale.). 1,as owner of the property,am exclusively convening with licensed contractors N Q FI AL PLU I NG consumer the project(Sm.7004,Business and Professions Code:)TW Contnctob Li- nts taw does not apply to an owner of property who Wilds or improves demon,and who convicts for such projeche with a contmemds)licensed pursuant o the Convacmrt License Law. - ❑l Wmtxemptunder S«. - .B&P C for this,ewon Owner Dam �O . WORKER'S COMPENSATION DECIARKRON •� Ihereby affirmend«Pendryrfp Cononsof thefollowinglog m1oT'3 Co Iheve pmvida for erumCertificateM of the Labor self-infortfortanker'sce of to O/J'W/rlllJfa/. r/ von,r provided for by Ss issued have 3]00 of the Labor Cada for the performance of the ave a ch Nia maintain is ismed. r - I have end will ude,fon Workers Compensation work hi h result.by Section /t _ ] of the Lkbar Cade,fordrcperformutce of Ne work for which this petits is issued. // My Wmkc/�r�pemattt�nalnsurancecsni«antll'.1w�n�tu�ba�ggeyk�{y aL (�'�L Caricr:�Is Y� Policy Nn t�0ffX{&' CERTIFICATE OF EXESWDON FROM WORKERS' COMPENSATION INSURANCE - (nns section need trot he completed i f the permit is for ooe hundred doll ars($100) or lms.) s , Toy. Rodno the performance ofNe work hich Nis permits iss,comphdl not<mploy an on in any ennerjbi1y rotheWarken'Compen- ution haws— Irs�. aro ''77��,, NOIRent Y NOTICEITOubj APPLICANT:IL after making this Certifn s of of Exemption,you shouts become Subject y it W ch pro Compensation provisions of theLaborCode,you must ' forthwith comply with tach provisions or permit shell W d«coed revoked. 0 p IhoCONSTRUCTION LENDING AGENCY rw Nrn that there is a consumed..lending agency for the perfouaxce of ^ Z the work for which did permit is issued(Sec.3097,Cls.C.) F., Lenders Name lenders Address W A 1 certify that 1 have read this application and sine Net the above information ng is correct. agr«to c comply with all city and<oumY madordinancessof and some feat r up ng e ' V ObWv,..miooccsogord hereby amhodurepnesentativn of this city to corer upon Ne above-mentioned Pmpeny for inspection purposes. , kr Fy (We)agree in save,indemnify and keep harmless the City of Cupertino against li.Mhum,judgmenta,costa and asposen whichnuy in any way a«me against said City - �., G] in eo sexi..ve of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY Win I ALL NON-POINT f..l z S REGUATIONS. - Signature of Applicant/Contnetor _f Data r/ HAZARDOUS MATERIALS DISCLOSURE Will theapphcanto,home Wilding«cupeo,stertor handle haurda.mmmind Re-roofs sec defined by the Cupertino ci Code,Chapter 9.12,and the Health and Safety Code,Section 25532(. Type Type of Roof ❑Yes Viii Will Ne applican orfumre Wilding occupant use equipment ordevices which All roofs shall be inspected prior to any roofing material being emit haradova a'v conwnin. .define by the Bay Arca Air Quality Menagament installed. If a roof is Installed without first obtaining an inspection °"ni`t' � I agree to remove all,new materials for inspection. Applicant ❑ ,as I hav<mad anrduus mamdah tryuimmcnts under Chapt«693 of Ne Gli- Understands and will comply with all non point source regulations. fomu Hee S y Cade,Sectio.25505,25533 end 25530.1 undersand dot if the buildin n nen arsons.Nat it is my m nsibiliry m notify the occupant of n1 is tPon'toisau c Cero so, pa�fm'allaf(/J� _ Signature of Applicant O With .red agentDaft Date All roof coverings to be Class`B"or better OFFICE