00030217CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
_ F/`
y 5- m ,A
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 Am th ertsel under provisions of Chapter 9 (rommeming
troll Section 7000)x, �in<ae amyProrsvionv Cotle, anE� li«nse is
in full tone Ree %i /��i✓b ZnT
u«nse n 2 ng
Dau Contacrm�[—
ARCNITE use DEC N
1 understand my plans shall W uutl As public rentals
Licenced Nofcesunal
OWNER-BUMDER DECLARATION
1 hereby airm that I am exempt from the Contravenes License Law for the
following .ssaA. (Section 9031.5. Buslnus and Prof.,bm. Code: Any city Or county
Which regimes es a permit m com act, Alter, improve, demolish, m repair MY structure
prim m its issuanm, Wm menims the applicant for such proad to file a signed atetemern
that he is li«nad pursumt m the provisions of the ConnutoraLicenre law (Chapter 9
(commencing with Section 7") of Division 3 of the Business And Pollination. Code) m
But he is exempt therefrom and the basis for the Alegcd axemoon. Any violation Af
Send.. 703 L5 by any rep he. fm Apemitil mbjeeta the Wti. m A civil pevlry of
not mon than Eve hundred dollam ($500).
I, as lone of the property, m my employees, with wages n their vele rompewtian.
will do Nework, and the structureisnotimU..ILBetefor vel e(5«. 90 Ade, Owner s
and .y who
code: The us. t ere Li«vin law does rot Apply n an Avenel of
property who builds or unproven therem, improvements veno does m<h wmk dedA r m tied for
his own employees, ptadde that such ldw thin trot included m Attend for
ale. If, Malec withhava the
ear an of rnem H old within ore yw r improve
du
nenWildcr will here the busOcn of proving Net he did nm build m improve fm par -
pose
1 of sale.).
0
ei As owner of Ne Sec. 7 y, . B exclusively c feed. g with : Thud enactor A to
construct 1W es jut (Sec. 71X4, Businu. and Py *bit builds
Code:) The ms thmmr'e Lid
cense law does Out apply pr je ts owner of property veal build. m imprmes Norton, and
who .. for rock projects with. conemmrf0licen.e punuanl to the Contractors
0
Licarr. ext
Tom exemptunder 5«. .B&PCfor Nis recon
ocr Dan
WORKER'S COMPENSATION DECLARATION
1 hereby affirm ander penalty of pedury ole of du following declarations:
I love end will Motion a CcoiOcate of Consent in ulf-insum for Workeea Comp.m
as provided for by Section 37M of the tabor Cade, for the performance of the
y for which this permit is issue.
l
have and will maintain Worm, Compensation lum uoe. As "dined by Section
IQoI Ore Ichor Code, for the perfarmantt of du work for which this permit is issue.
oflr%CorRoovatinn IA:mr.•M carrier and PAIicYliarpbq 9^A _ n !'_ 6'7
CERTIRCATE
(Thix merma had trot becomplcted if Ne permit is fmone hundred dolls. (SI W)
or leu.)
1cenifythatintheperformameof NewmkforwWch Thispemtilisimu Ishan
Amt employ any person in Any mento, a .11. become eubjmr a du Woken' CAAAPm-
.tion laws of California. Dan
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become Subject In the Worknev Compensation provisions of din Iabor Code. YW most
forthwith comply with such provisions or Nis permit shall W deemed mvokcd.
CONSTRUCTION LENDING AGENCY
I hereby aRnn thss then is a construction lending agency forthe performance of
da wmk for which this pemtit is laude (Sec. 3097. Civ. C.)
Lenders Name
Undoes Addnu
I certify that 1 have read this application and state that the above information is
correct. I ague to comply with all city and county mdinmcn and One laws relating to
building constrolmn. And hereby authorize npnanativn of this city to enter upon the
abovc.mentione pmpeny for Inspection puryoua.
(We) agree m ave, indemnify and keep harmless the City of Cupertino against
babilitia.jndgmena, coetaend expo }� which may in Any way nccrve ageinsuaid Ciry
ieconaqueryu dagannn�afehi/ rioni"
veer 1C T' t ",ANI A kfWll.l. (:OMU Wlfill AIA. NON -MINI'
HAZARDOUS MATERIALS DISCLOSURTe
Will the applic.. or future Wilding ncl.Wt.mo or MMI-hasaNnus material
As defined by the Cupertino Municipal Cohn. Chapter 9.12, and the Health And Safety
Code. Section 2d5320.07
❑Yes (
Will 1W Applicm turn. Wilding eccupim use equipment mdevices which
mit hamoom, Air coma ommix As defined by din Bay Area Air Quality Management
Wn7
❑Yes
I YA rat 4 ' ma s rtgsri.menu under Cnelxce b.95 of Ne CAb
Ionia HCA( a y Code, d SUS, 25533 and 2553,.1 undersand that if the
Wilting m My te m, dm dis ponsibilirynnmifY the «cvpmt
o[the ah must t eotaC e / up9CcY�
Qw reuUm Wage Dthe
At to /,;7 NIC
gcf7c& ❑
— ov 5-5
S�z.grz
Sq. FL Floor Area
Re -roofs
Type of Roof
Job Description
/40-9 N ers
6?50a I
FINALED
JUN 0 4 2001
BUILDING
3i-Oo
All roofs shall be inspected prior to an 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
Date
All roof coverings to be Class "B" or better