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BUILDING DIVISION PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hereby adfimt Net 1 am licensed under provisions of Chapter 9 (commencing
.ib Sation 70W)of Divitio fineRmi'rcnand 'o&ni recons and myli<ense is
in full force end eRect.
Lie nwC _ LiaN
Dem Con
ARCHRECTS DEC DECLARATI
I undersand my Plans shall Ignored u public records
OWNER-BUH.DER DECLARATION
1 thereby effrm ohm 1 am'exemp' from We Conrramrs License law for the
following ... (Sation 7031.5, Rostrums and Profession Code: Any city errunty
which requires a parrot to construct, alter, improve, demolish, or repair any structure
print to its issuance, Mae oupstres Ne applicant forsuch pemdl m file a signed statement
that he is licensed pursuant to the provisions of the Contranofe License law (Chapter 9
(cummc'uing with Section 7000) of Division 3 ofnba Beaune. and Pmfeaiou Code) an,
Dur he is exempt thaefrom W da basis for the alleged exemption. Any violation of
Section 70313 by any applicant for a permit subjects the applicant to a civil perry of
rot more than love ho wood dollen ($500).
wi I, ate owner of Ne Preyencwm ig mt int es wiN wags u mei( role compeummu
will doduwork, ands: Cmeis two Intendede offLaw does
to an Bees
and arty who
Cade: Tha C es the rte Liana law tl su na ds hires lf owns of
his o nY who builds or improve t such improvements; and who Cosa tech wote himself or ded for
hie own employes, provided Nat tech tisold arc not intended n offered for
ale.If, however,Ne ere the unen of proving
issolde didinoneyevafmroveforthe
awnenbuildcr will love dR burden of govin8'Aat he did not build or improve for put.
co I. u owner of the Sac. 70property am merger, elyand confession$ CIN licensedTheCconbmors U. constructaLa the projat apply
o an own"
ole end rry, who
Code:) The a thenors nal
wWe law does rot apply e ts own. of pruperry, lice Wilde w improve thereoa rob
whanse Law,
a , ler ructh go)au with •mnuacmr(s) licensed pursuant b Ilse CanlrKtWa
license law.
❑lam exempt under Ba. ,B&PCfar this rcaaon
owner
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declanuona:
I lave end will maintain a Certificate ofColuem to al6i'num for Workers Compere
tion, as provided for by Section 3700 of the Lata Code, far the pafom'eae of the
ff)rko which this permit is issued,
have and will maintain Workers Compemuion Imurance. as hatched by Sation
37M of due Lata Cade, far the perfonruuce oftlm work for which this permit is issuod.
My Wortels Cwyi�t. alprrs$ytpatarti. and Policy nu�nW�n
Cama'J i'f/nae/ PoIicY No.:�r yXm
CERTIFTCAB OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This .colon need not becompleted if the permit is foronehondrasdollan (5100)
or leas.)
I certify that in the performanceofshe weak farwhi,h,hia met is issued, l shall
nm employ any person in any manner m u to become subject m the Warkm' Compen-
ution laws of Califomia. Data
Applicant
NOTICE TO APPLICANT. If, after making this Cenif,me of Exempum, you sW.W
became subject to the Workdr Compensation provisions of the Labor Coca you must
fordwith comply wit such provisions m this permit shell W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat Nem is a construction lending agency for the performance of
Ne work for which Nis permit is issued (Sec. 3097, Civ. C.)
banners Address
1 unify dw 1 have sed thio application and In 'her the above ifforom fern is
correct. l agree, to comply with all city and county ordinances end ewc laws relating to
building conmucnon, and hereby milwrize repesenwivs of this city m enter upon Ne
above-nramimed property fm Io waon purposes.
(We) agree to ave, indemnify and keep humless the City of Cupertino agalmt
liabilities,judgmenu, cuts end exprnses which may in any way acme ag.last aid City
in consequence of she gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1. NON -POINT
SOURCRREGULATION��
i� C�,f�-�—l-J
Ssguacwcof Apphc JConvsster
MATERIALS DISCLOSURE
Will da applicant or future Wilding occupant uwe w handle harardoue moment
as defirud by the Cupertino Menai I Cade, Chapter 9.13. and the Health end Safety
Code, Section 25532(a)7
C] yes R0
Will the applicant or future Wilding acupant use equipment or devices which
emit huurtlous ab conumiwnu as defined by the Bay Arca Air Quality Management
District?
❑Yes (gH
1 have rood the havrdsus cuuriale sequimments under Chapter 6.95 of the Cali.
fornix Hadd, & Safety Cade. Sections 25505, 25533 and 25534.1 uldnetattd that if Ne
Wilding does ON currently have a )chant that it is my tesponibility mtmtify the pen'
of she reyuuemenuyiWFh most W me' Inner mougumee of a Cmif s)( D
�— s /
Owner or euth zed eget / Data
CONTRACTOR INFORMATION:
hot ulw*l-i/v- ��9' -ifsV
2s3i 9ra��/or�c/ 9a�
Re -roofs
Type of Roof
retsmss nu.
ODOL}boo�
Fol
Job Description
14p/me �dPo�p h2inter
64115E D
Floor Area
JUN 2 1 2001
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.
V 1 3 LdIOd
Signatur of Applic• t Date
OFFICE
All roof
to be Class `B" or better