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CITY OF CUPERTINO '
DING DIVISION PERMIT CONTRACTOR
R 1 I11 1 U r' 1 /-nI/�j �jt/y/1�/ ��,(�//�J
NAME:N&r, Ed I ��%� I VI/•t�V// UN ✓ f.
25
7/ENGINEER 5l0',2y3 ZD/2
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Na 1 am licensed undo pmviaions of Chapter 9 (commencing
ithc
Snor7000)or DivSian3afshe Busircsrand Rof ions Code. andmrs
ylveris
mfnR fame ted effeel
Ijcrnu CLa. Vox
ARCHITECTS DECLARATION
1 undaleusd my plans "t be used a public records
ticreaed Prefeasinw
OWNER -BUDDER DECLARATION
1 hereby affirm Nall am exempt from Ne Contractor's License Law for the
following mason. (Sari. 1031.5. Business and Prufessimu Cade: Any city or ooumy
which requfies a .it . marru t. d -r, improve. demolish, or spur any or uc.m
prior m its isswna. dor requires the applicant for mch permit o file a signedstatement
that M is licensed Durant In, the provisions of The Conaaclor'e Lirrnu law (Chagrs 9
(mormancing wish Section ]000) of Division 3 of she Business and Profession Code) or
Nat he is exempt therefrom and this basis for the alleged exemption. My violation of
Section ]031.5 by any appliant for a permit wbjau the applicant to a civil pemltY of
our more Nan five hundred dollars (SIDE).
(-] I, as owner of the pmpeny, a my employes with wages as their sole eonpensa or.
will do Ne work, and Namorture is not intended ar iffcmd tarsale(See 71ts .Business
and Pmfe.ions Code: TM m
CoaclWY recome, law does t apply an owf of
progeny who builds or improves Ihrmon, and who does such work himself or through
his own employees. pmvidW the such impmvemems tic nor intended or offered for
We. If, however, the Wilding or impovemcnr is sold wiNino. yuraf mmplai.. The
enbuilder will have the burden of proving that W did not Wild of improve fm pur-
aof we.).
❑ I, as owner of the pmperty, am exclusively estimating with limmed contractor to
.ami the project (Sec. ]OCs, Boniness end Professions Code:) The Contnamr's U.
an law dnea not apply to Now am of property wW Wilds or immi thereon, and
who contracts for such pojeets with a commie or(a) licensed punaenuo the Contractors
Licenu law.
I am exempt under See. . B & P C for this rusan
Dona Du
WORKERS COMPENSATION DECLARATION
1 hcaeby arm unser penally of perjury one of the following dcchoselices:
'J I Mw and will nuinuin a Cenihceu ofComent ro self
he insureWoheh Compere
'tis. nes provided for by Secdon 3]00 of Ne tabor Code, fm the performance of The
oohJJ�wfwhich Nia pmdl is iswed.
tSyihue and will maintain Worker's Compensation work
for which
his perm by Section
3TOOof the IaWf Code, for Nc peAomance of the work far which this permit is issued.
My W«ms
kerf,Co 1. Insyra or taend Policy mt,," ./2V�//l/�
Carrier: yi Poo
licy N.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomPleled ifthe permit is forme hundrecdolless (SIM)
Or Lasa.)
1 candy Nal in the performance of the work for which this emii is issued, l shall
has employ any pecan in any manner w u Or breams subject to the Wahcni Compery
.tion laws of Cdifomie. Data
Applicant
NOTICE TO APPLICANT: If, aBa making this Cenifcate of Exefopi.. You slwuld
become subject o Ne Worker's Compensation provisions of she Laws Code, you must
fanhwith comply with such provisions or this permit shit W dccmed (evoked.
CONSTRUCTION LENDING AGENCY
Q I for which
this
Vpe there is sued (m . 30lending agenry fmtM perf.nerce of
Z Nc work for which Nis permit is issued (Sec. J09], Civ. CJ
Lenders Name
a % lender's Addrecx
1 anlfy rhes 1 have read Nis a;,brali. and stale that the above infomution is
6 C .1. l agree so comply with dl city shad comm, m comers and slnc laws selaling to
= Z building construction, and hereby amhutiss repesemmives of this city to enter upon the
U 0 abovcmemionad property for inspection proposes.
L. E... (We) agree to save. indemnify and keep harmless the City of Cupertino against
Q t.) liabilities,judgments. costs and expenses which may in any way accrue against said City
�.r (s7 in conuqucnce of Ne granting of Nis permit.
F h IT
APPLICAN'I'UNH:RSANDS A N D WILL COMPLY WITH At.]. NON -MINT
V ti SOURC�,xEGU1.Yl'IONS. f11s/�U
Signore of ApsicantiCommulor !DDaate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant stare or handle herardaur material
a defined by the Cupertino Municipal Code, Chapter 9.12, end the Health and Safety
Code. Section 25532(a)]
ClYes )6-
Will
oW II the applicant Of future building occupant use equipment or devices which
lift
mit harudwI air onuminants//a''s defined by the Bay Area Air Quality Management
0few
�No
I have-
the harardms maendr reyu"non undeur h95 of the Celi
r ramie xWN A So ty Code. Swims 25105.25133 and 'Clout2553x. I;
ertand Dor if the
forms
Hdoes nor curren0y haus a tenant, Nm it Ls my tespansibi...a'r'y the occupant
of Ne mquimments which must he Isar prim m Hwerce of sNe which must nater prim of a Ceni�cWencyv
owns ar.aNcroad agrou�((��
Job Description
0
Re -roofs
Type of Roof
R
IVIV rttVL0
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 wi I comply with all non point source regulations.
. �tg/�V� 011s/(fv
Signature licant Date
OFFICE
All roof coverings to be Class "B" or better