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CITV OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: A ;, � �Fl —7
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l/IiNGINLER
LICENSED CON IntAC1OR'S DECLARATION
I hereby aRfm Out I sm liccused uoda provisions of Chapter 9 (commetwing
with Section 70(0) of Division 3 of the Business and Pin&W.us Code. ark my license is
to fun fora and oflec�_�� �-L
License Chas tic. «
Den at, contractor
_'
AR.. DECLARATION
1 undenund my plan andl be uxd az public tawrds
Licwad Prefeasumal
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from Ne ComnetMs License law for the
following u (Section 703 LA Business and Prufcuions Code: Any city or, county
which oxides; •permit to const cher, improve, demoliN, .r repair any awmme
prim no its icourne, elan taryires the applicant for such permil w file a signd 4itam it
Out he is licensed puauant to du provisions of the C...actor. license law (Chapta9
(commencing with Section 7000) of Division 3 of the Business and Pwfessiou Code) on
that he is ciempt therefrom and On buss for the sllcged exemption. Any viokdan of
Secom. 7031.5 by any applicant fm a permit subjects the applicanrin s civil penalty of
out mon then rive hundred dollen ($50().
� d.azowncr of the pr.pcnYormY emPloycea with ws8esu they ante compewdon,
will doth. work, and the evuctun is not imended m ase do fm o apply oOan Buehna
and Prty who
Code: The ova. avtm i License law tines Iwt apply w If owner of
his a Y who builds pu improve. thcmm, any who dos such work himself m Wwgh
his own however.
provided Nat such impms sold w mi not inmkcd m oHaed foe
sale.If, however,the have
he g.rimprovemwtie is, within one ildori pious, for the
Cir -W striae will hive On Wtdcn of provin6 that he did not Wild or improve for pm -
pose of sale.).
1, an owner Of the property, sus exclusively convecting with licensed connacwn w
coustrua the project (Sec. 7144. Business and Profeniom Cock:) M Convenor'. V-
ceme Law does but apply w an owns of property wW Wilds m improves come W. end
who contracts for such projects with a comostor(e) licenced pursuant to the COmtectots
Licenselaw.
❑ I am exempt under Sm. �� /J . B & P C for this reason
Go, L� //L.I /L Dant
W. up,I'GM.S�M770N
I harry affirm under penalty of petiory ane of the following declamations:
'-j Iheve and will rminwns Cenifl=of Com ttoulLinsumfrrWorketsCompen-
ine, es provided for by Section 3700 of the LaWr Code. fm the petfamnnce of the
mk for which this pemtit is issued.
❑ 1 have W will maimem Wnrkcrs Compensation Imufaae, as required by Salion
3700.1'6. labor Code, for the performance of use work for which Ni. permit is sawed.
My Woftes Compensation Insurance center and Policy number are:
Curia: Policy No.:
CERrDgCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ranorr ad not becompletW ifthe permit is forms hundred dollars (1000)
or leu.)
I certify that in the perfomwce of the work for which this pemtit is issued. ) shall
not employ any pent. in any Imnner w ton, tMiecN6lbe W.rknd (:.r9pen-
utioicator of California. Dae -
Applicant
NOTICE TO o the WoT: If, Co this Cisionse m Exemption, you should
become su rung, to the W.rh mCtions or this ernift Provisions of the LaWr Code, you muss
forthwith amply with such proviniom or this permit shell W domed evoked.
cONSnUCTION LENDING AGENCY
Q O Ihereby affirm bar Ogre is a construction luting agency for the perforrrunceof
Z =the ..it for which Nis permit is issued (Sec. 3097. Civ. C.)
untices Name
a = bender'. Addreaz
ry) I cenlfy then 1 have read Nie application and au¢ that the above information is
0. Gcmi I agree to comply with all city .red ..my ordinances and num laws W-6-1 no
7 building conahucimn, and herebyautWnu nlnesenWives of this city no ennr upon the
V G above-memimed property for inspection purposes.
I.. f" (We) .gne to uve, indemkfy and keep harmless Ibe City of Cupertino ega'u4t
O U babilmex.jedgnenu.cosuaM expenses whim may in any .1.. sgaimn said City
;,. W in r.mer crcc a the gmndng of this Famous.
[+ IL APPI.ICAN'1'UNDIiHSI'ANDSANOWII.I.COMPI,YWIrHAI.LNON-IY)IN'1'
C.) z SOURCIIHIiGU1.AHONS.
?
Sigmwre of ApphcanVCon=¢ M �/Oats
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or &tun Wilding occupant ams or hwNe hazaN.us manrial
as defined by the Cupeni. Municipal Code. chapter 9. 12. and the Hekth and Safety
Code, Storm 25532(.)4
❑Yes �V
Will the applicant Of future Wilding occupant use equipment or devices which
herudws an concerti Flnod by the BaY Arca Air QualityQualityMwtw
g<nt
Dsu t1
❑Yex
Dovx No
I have Bad the haardoux ma trod. son mincmx under Clo au 6.95.f me Cdi-
fume Heal, k Safety Cade, Sections 25505, 25533 and 25530. I uMenlwd that if the
Wilding doer rot currently love a mm�t, the it n mY nsponsiMlity w nasty the occupant
Job Description
�vz3/J a
Sq. Ft. Floor Area
P
T 'Yr / W /3
0
f OQ
MAR 13 2000
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
understands and will comply with all non point source regulations.
/,-- 3//J i—O'riv
Signature of Applicant Date
All roof coverings to be Class "B" or better
OFFICE