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BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
AW Na .AL,
'SNWT NAME: V �l Q `J(/(,/
Mpg M�t�f-7 oA- I
08. �ISy3 �Li..I �3�g
'ELT/ENGINF.r:R
LICENSED CONTRACTOR
1 M1meby .f firm that T the licensed undo
dion )000) ofyDisuatue 3 ofthe Business
candcgde i
lean lJ
IF OW NER-BUDDER DECLARATION
I hcheby affirm that I ern exempt from the Conmetors License Lew for the
following name. (Section 7031.3. Business and Promadures Cade: A, city or..my
which requires a permit hall
the alter, improve, demolish, or repair any awctae
prior mits cense Isalsonquitns she hili of for such Icrdtmm asignedstamment
Net he if licensed pursuant tome provisions of the Conrrmtots Licmu law (Clsptar 9
ft, be is recoup.
t5eetione and t f Division 3 ofthe illegal
Imand Professions Lure. a
Wt io is 31.5 b therefrom and foie buffs for the cos the uempent ton. a civil
rmlation M
Section thom by anyapplicant
dollars
•permit mbjast the applicanno .civil pe,Wty, of
not mote man rise a Wom don.n RSao).
❑l otowaork. udpmprocc e,myemploymawW wratha. ohei(Sm crmername.
will dome wort sad the laic Comic red. tended!Livens or oRcnd fa We WY to iim Business
and Prfeuions Cakr The Comnctor. i License law sou tat apply to lf owner W
progeny wW Wilda or improves thereon, thrid veno food n, n tinte himd d in of through
for
his own employeese pmvidad mu such impms sold within thin not intended a oHcrnd for
ole ILhowever.thebuildingorimprovementissoldddoneyeanr initiative
the
er Wilder will have the burden of proving that he did not build a improve far pur-
pose of Wa.).
1, as rivers of the property the exclusively contracting with lianaad crnwdrn in
convect the project (Ser. TM,, Business and Professions CaR:) The Contractor's Li-
cense law does., apply to an owner of property who Wild.., eons. do mer. and
who contracts for such prejecs with aconummr(q licensed pursuant to the Contractor'a
License Law.
❑ 1 am exemp under Sm. . B & P C fa this ressrn
Owner Dan
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of pe jury one of tW fallowing dalnaliou:
❑ l len ..M will.inuin a CeniOcne of Corrsenuo wif.insum for Workei sCompcn-
urinn, as providad for by Section 37W of ft Labor Cods, for me perforstere of the
k for which this porus is issued.
1 have and will maintain Worker's Compensation Insurance, as required by Section
3 of the UW, Cons, for me performance ofthe work for which this permit is issued.
My Woh$g1C neatim lr�w rfce yea and Puhcy,.aQ4ryuj:A k M g2jE
CERTIRCATC OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action need not becompined ifthe permit is former hundred dollen ($100)
or Ica.)
I minify that in theperfmmumce tan ak ft wnicnthia permit is issued. I shall
run employ NY permn y men o Y 'ct m the Worker( Compcn-
Apirn laws of CJ'
AOrCEt
NOTICE TO AP NT: If, after making this Certificate of Last, C di You should
become subject to the WOM's Compensation envisions be,
IaWr Cade, you must
forthwith comply with such previsions or this permit Nall be deemed revoked.
CONSTRUCTION LENDINGAGENCY
Q I hereby aRrmthat dim, is ac.nsmsetirn lending agency for the Performance of
rZs the work for which Nis permit is issued (See. 3097, Clv. C.)
Leaders Name
(Y 7 L<ader's Address
(,7] I certify d n 1 have read Thu application and some that tad above Irdoroti0a is
d 0 umo. I agree to comply with all city and county ordinance and state laws relating to
C.I O building convection, and hereby authorize ecpnsenwives of this city to enter upon the
move•mertloned pmpeny, for inspection purposes.
(We) effuse m save, indemnify and keep hamulus the City of Conniff. against
Q V lieuditie, lndgnters , most and expresses which may in my way accrue against said City
in
mmo,uurce of the gmt
uing of tis permi .
H In APPLICA Nf UNDHRS'I'ANDS AND 11. CD.NVLY WITH ALL NON''YOIN'
Sol1RCl; RF .AI IONS. 700
'gwu M ucanUConrador Dao
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fmum Wilding occupant store orhandle hassNons material
as definW by the Cupertino Municipal Calc, Chapter 9.12, and the Health and Safety
Coic. Section 25532(.)'! ��•
❑Yes G o
Will the applicant or future Wilding occupant use equipment or devices which
conk haurdous air conwairs me as defined by the Bay Mea Air Quality Management
Disvlc@ /
E] Yet
1 have thud the hewda, mnmala mgrtinmmn made, Chapter 695 of dial cal,
fomia Health & Safety Code. Sections 25505, ZS and 2333,.1 understand that if the
building does tatccgign haveammm�4 maW- Y nctponsibilitymnotifytheacuppnt
I IJG
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000501 3<v
ANITARYNO. I APPLICATION SUBMr
N/C CONTROLM
❑ BULDING PERMIT INFO _
Job Description
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q. FLIrArea Valuation
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NVE
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Re -roofs
Type of Roof
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
u;0:
ders s and will mply with all non point sour a regulations.
iigre of Applicant e
OFFICE
All roof coverings to be Class "B" or better