00040180CITY OF CUPERTINOrcRmu nv.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION::&V O
BUIL DING ADURE.SS:
(err aLtfffko 1( , SANITARYNO. APPLICATION DATI
O ER'SNAME: •VL',`V•'".`�j �VI N a/ (n✓Y ��GH(/I�� � r NIC el-,)-8
HO ����r` S♦ l� ❑
— 90l0
ARCIII'I ECfIENGINEER NULDINLi PERMIT INPO
LICENSED CONTRACTOR'S DECLARATION
I hereby alfinm that I am Rcewd under provisions of Chapter 9 (commencing
with Sectimn My, o(Division 3 of the Bitslte.. and Rofalou Code, and my liceue Is
in. fall force ande `Lx& Lic.N 4�
De¢ VV Contrumr
ARCHITECTS DECLARATIO f
I mden..nd my plains "1 be used u publw records
Located Profeaeional
OW NER-BUILDER DECLARATION
1 he shy aRmn that 1 am exempt from she Conhumrs License law fm the
following tisun. (Section 7031.5. Busi.ss and Profaiom Code: Any city a Monty
which saloons a Permit mea 1. titer, im.ow, demolish. of 11W any emetme
from to its routine , also ""aims this applicant fa such Perot w File a signed astemcnt
mat he is licensed pamorm, to the provisionsof Ne Ca bsurora License Law (chapter 9
(commercial, with Section 7(00) of Division of the Bad. and Professiam Code). -
that he is cum, therefrom and the basis for the alleged exemption. Any violation of
Sutton 70313 by any applicant fm a permit subjects she, applicant to • civil penalty
nM more man five hunde,d dollars (5500).
❑ Lav owner of me Oropeny, sir my employee with wagesumeir sole compensati
will da the wont. mdthe ma com is nor i... nadmin.1yond for sale (Sec. 71314, Budn..
and Pmfeeioe Code: The Contractor s U.rot law doe not apply to an owner a
propcny who build, or iso ave thereon, and who does such work himself or through
his own employers, pmvided that such impmwments se, nor intended m -Repeal for
sale If, browever, he building or improvement is within one year of completion, the
awmacr-Wilftr will hew the bonen of mvin, the he did nm Wild or improve for pa-
p aeof We.).
O 1. as ow.r of the property. am exclusively mmoscong wish licensed contruaoa to
ontract me project (Sec. 7W, Husirss, and Professions Code:) The Contactors Li-
st Law does not apply to an owner of proper, who Wilds or improve. thereon, and
who contracts for such My cia win a contnmar(q licensed pursuant in the Contractors
Licca. law.
I em exempt under Ser. . B & P C fa oris teuov
Owner Date
I WORKER'S COMPENSATION DECLARATION
I hmeby affirm ander penalty of perjury, one of the following dalamtiou:
Q 1 have w, will maintain a,mb cote cronuent.self-ionsm for Workers Compact.
..tion, as provided for by Section 37W of me Labor Code, for the pcnfrmance of the
work f c suis permit is issued.
ave and will meinain Wntker'a Compensation luuruse, as n,uircd by Section
37M of drc labor Code, for the perfwmuse of the work for which his permit is issued.
My boor sitcom per I rauc`.nrie. Policy PnhtY Y."2 SS
Conic A r 1 Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This cation need was be emnpleteci if shc permit is for ms hunde,d dol horn (5100)
or las.)
1 codify that in the perfomtanceofthe work for which this permit is issued. ) shall
not employ any Penson in any mmner m as to become .him' m the Workers' Compen-
vlion Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after malting this Cer, ificate of Exempdom you mould
become subject m the Workers Compensation provisions of the Labm Code, you must
forthwith comply with such provisions or this permit shell W kamcd mvokad.
CONSTRUCTION LENDING AGENCY
I hereby, sRmt toot dart is •wutruNan lending age.y for use, Perfortrwse of
the work for which this Permit is issued (Sec. 3157, Civ, CJ
Lenders Name
Lenders Addmss
I cmify the 1 have null his application and arae that too move ii.l. on is
mmacc l agrtc to comply with all city cad county on iraues and a..te laws tvbting to
building concoction, and hereby miotics representatives of this city to enter upon to
m ovemtmioned property for inspection purposes.
(We) ogrea ra oras.. indemnify and tap humleas the, City of Copcnitm ag+inat
lubilidu,judgrrcnu. cos,, ma, expensss which may in my way ace.. agues to City
in
conscquenw of m, gmnthng of this pemdt.
APPLICANTUNDERSI'AN AND ' LLC OMPLY WITH ALL NON -POINT
'IURCERIIGULAI' )'
Signa Appli tCantut Date
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or fume, Wilding occupant
ps smro or and
W eardous material
u dcftned by the Cupertino Municipal Cade, Chapter 9.12, end too HedN and Safety
Code. Section 25532(11)?
❑Yes ❑No
Will the applicant or future Wilding occupant use equipment or devices which
bl,ot heen nis sir conaminm,, as defined by the Hay Arm Air cas ity Mmag.mcnt
Oyes ON.
1 have read the haurdaus centrals sequin meet. under Chapter 695 of the Cali.
fmnu Hulm & Safety Cade, Seotioe 255115, 25533 and 25530.1 undersand mat if me
Wilding door na cuncmlY have a tenant dot it is my rtiporuibility tonaifY the omtpmt
of she mquieerlems4IFtich ygst he meapior to issuvec of a Cenificue of Occupancy.
Orlin, nd agent - Data
Re -roofs
Type of Roof
I
Job Description
�/�
X00
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