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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
PERMIT NO.
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SANITARY NO.
SUB TTJDA�T
APPLICATION47-
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O NER' N ME
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ARCHITECTS GINEOER
BULDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I w licensed under provisions of Chamber 9 (commencing
withScelion]000)ofDivision 3 ofthe Businsaasdi Proferrioas Code, and my license is
Ufull epee W CRK1.
ate Class LiaN
D
Done Con DECL
ARCF I W used
DECLARATION
1 understand my plus a1Wl be used u public rceads
OWNER.BMDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
follwine ... (Senior 9031.5. Business and Prufeasions Cuda: Any city or county
which requires a permit to cauwcr altar, improve, demolish, or tepav any atrucwe
prim to Its issuance, also rox mms the applicant for such Fermat to file a signed statement
that he is llLeved ponuare m the provisions of the Contractors License law (Chaprer9
fcommencing with Section 9000) of Division 3 of Ne Busineu end pmfecaiona Code)or
Nn be is exempt du refim. and Um basis for the alleged exemption. Any violation of
section 7031.5 by any applicant for a penrdt subjects da applicant to a civil p.Wry of
nee more than five hundred dollen ($501).
❑ 1.awmr of the prom., m my emPlryoa with wages as thea is eompewtion,
will doth. work, and Ne stmctun is norinnendedmoRetnd for We (sec. 900th, Bummus
W Professions Code: The Contractor's License law does nee apply to an owner of
property who builds or improver thereon, and who does such wo& himself or through
his own employees, pmvidedl that much improvements ate nee intended or offend for
We. IL however the building or improvement Is said within We yearof complui se, the
r Ida winve hathe Wrian of moving dust ho did tont bunm d improve fm pu-
pore e^).
tt of the progeny, an exclusively connecting with Bcenand contractors to
construct the project S. 7044, Pusateri and Pmfesdons Code) The Contractor's U -
c n.law cher not apply to an own. of prop.y who build. or improver thereon, and
who contract, for such projnc with arontract r) licensed punan
ut. the Contractors
license law.
C]1 em exempt unde , B & PC for this reason
Owner
WO KE.Rdoctor s C PEN perjury
W DECLARATION
iAanby affirm undo Confi neperjuryons of tis(dimingdKlaas Cor
❑ Ihave and will for by eCtion37 cofCo TaWrCode.fomfmwarmancempen-
work f as provided (Pe by Section 3900 of the Labor Cdr, for the performance of the
work for which this permit is issued.
❑ 1 have and will ode, for a pstf'a Compensation work
for
or which
as required by Section
My oftAe Isom Code,for thepencecamerftiswork forwhich Nia permit is jawed.
Ca Worker's Compensation Insurance cirri. and Policy number tie:
Cartier. Policy
CERTIFICATIE OF ION MOM wORKFRS'
COMPENSATION IN 1isfuE
(Tuffs section need not be completed i(Nc pe.mnl is forone hurdrtd dollen ($100)
m las.)
I ceni(y that in flue perfomarse of the week for which this permit is inat1M.I mall
net employ any permit In my mender b as to become subject to ds WorsenCompcn-
samo laws of California.. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cenifiean of Exemption, you should
becottn Subject to the Workers Compensation Provisions of the Labor Code, you most
forthwith comply with such Provisions or this permit shall nd domed revoked.
CONSTRUCTION LENDING AGENCY
z p Ibcrcby mine that then is a comumcdon performance agency for the perfounce of
Z the work for which this permit is issued (Sec. HN9, Civ. C.)
F.. 4 Lenders Name
C > Tenders Adelnas
LI onifY the I have nail Nis dNe application and sWe al move infomudon Is
coned. I agree to comply with dl city and county rod" ances and ante laws reheAng to
Z) Obudding conspvetion,endhemby mororio representatives of this city to enter upon Ne
above-memioned mopeny for inspection purposes
Lel [r (We) agree to save, indemnify and keep harmleve Ne City of Cupenum against
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halt judgmunts. casts and expenses which may in any way eccme against aid City
} W in consequence or due graving a this permit.
F Q' APPLICANT UNDE !NDS ANU WI , COMPLY WITH ALL NON -POINT
SOURCC Rlic'uI S.
�St,,xrbm pphcxmsZmlr` Dae
H RDOUS MATERIALS DISCLOSUIIE
Will the applicant or future Wilding decupent soon or hurdle A comoh.s maWial
as defirsd by the Cumnino Municipal Code, Chapter 9.12, and the Beaith and Sidery
Code, SKrio t 25532(a)l
❑Yes ❑No
Will the applicant of future building occupant use equipment or devices which
mit becandoa etr emuminnts a' deli ud by Bs Bay Ara An Quality Management
• Dixuin9
❑Yes 7 N
1 have reed the hanrdats matedair requinnorm under Chapter 6.95 of th Cab -
forms Halth & Safety Code, Section 25505, 25533 and Z5M. I understand that if the
bundingdaa rep veaswy(IAa it is MY responsibility to nobly the acvpant
cf the ngoncment � h mut be Cr prions m iswance of a Cmifcae ofo o,sony.
need .gem Dale
/ V gL
FL Floor Area
Ke -roots
Type of Roof
Job Description
azo
e 0ky,&�2
( -671/
All roofs shall be inspected prior to an yy 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