00030004CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR.INFORMATION: ,000
38 : 9_2/-11W6
LICENSED CONTRACfOR'S DECIARArlON
I bereby aRren tot 1 sum liccesed order provisiolu of Chamber 9 (onmeaceing
withgection 9mi clflot Division J of the Bu.imu and Rofeuions Code. and my littnse is
In fell a ch sss tCl.
ce
ILnse Cuu _
Dam ConDECI
As "I b use DECLARATION
I undcntaM my Plans shall W used as public roads
Uttered professional
OWNER-BUR.DER DECLARATION
1 hereby infirm tial 1 w exempt from be Contradict. License law fa the
following reason. (Section 9031.5. Business aM Profbuiou Cuda: Any city a county
which so,mea a permit m construct, .Iter, improve, demolish, of repair FuY strvcmre
prim to its issuance, also rydms Fite applicant for such permit m file • si'mid.lemment
Fiat he is licensed pmmum m Ne previsions of Ne Contractors License Law (Cop"
(commencing with Smuon ]0(0) of Division J of the Box. sed 9ofession Cade) a
Wt he is more, therefrom ab the limit for Ne alleged mempuon Any violation of,
Section 701.5 by any applicmt for a permit subjects the applicant to a civil penalty of
not mart then Eve hurtthed dollar
I, u owner of the mopeny. or mY emPloyus with w...F is Neir..le cmnpeasume,
will do thc work, tad the mcwm is twt inteacWd moMcred emsale(Sec. ]0ae, Business
W Nofaal.. Cods: The Contracimh License law don ret apply t. an owner of
property who builds or improves Hereon, and who does such work himself ne through
his ow. emplayma, provided dtu such improve.. m nor imam ed Or oRched far
We . If, hoverer. the builds, or ion ovenamt Is sold within one year of completion, the
owner -Wilder will have the burden of proving that he did not Wild Or improve for pro-
pose of ule.).
1, ex owns of the property, .m exclusively contracting with licensed contractors to
construct the project (Sec. ]OU, Business and proposal. Cuda:) The Contractors V-
ceme law dues not apply tom owner of property who Wilds or improves thereon, tad
who contracts for such projects with a rontractMq licensed puruam m the Contractors
L rose nese.
❑lam
ex�Wo,
_ .B&PC7for Ni's reason
-Owner Dalt
COMPENSATION DECLARATION
opinedty of perjury me of th<fallowioe declamtioa:
I I have and will maintain a Certificate of Consent in selLimurt for Wmkerra Compere
ion, as provided for by Section 3700 of Ne Labm Code. for the pro farm ce of the
wmk for which this permit is issued.
El I have surd will maintain Worker's Compensation Insurance, as required by Section
0700 oldie Lehm Code, fur the perfe. airline work for which this permit is issued.
My Worker s Compensation Insurance turner and Policy number art:
Carver: Policy No.:
CERTIFICATE OF EKEN4MON FROM WORKERS'
COMPENSATION INSURANCE
(This section acial me becompleted if the peri it is foroachurlAed tbllus (SIW)
or loin.)
1 certify that in the perfmormax, ofthe wmk for which this permit is issued, I shall
ren employ any prow. in ar, manner so as to becwtne wbjecuo dr. Workers' Compn-
sation Iaws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Cenifiate of Exemption, you should
become subjdt to Ne Workers Compensation provisions of the labor Code. you must
forthwith comply with wch provisions or Nis permit shall be deemed rooked.
CONSPRUC'nON LENDING AGENCY
Q Q Ibeabyaffirm da there,, a cooauemm[.Win, agency for lbe perfutsance of
Z the work for which this permit Is Issued (Sec. 3097. Civ. C.)
Lenders Name
�i > Iatelme Address
(]]I cenify that 1 have read this application and sac tot ted aWvc information is
0. A correct.I time, to comply with all city and county ordhtances and shalt laws ¢lacing to
fi 0 building construction. and hereby sodium. rtprssnaivn of this city to mor upon the
above-mmumned paprny for impaction purposes.
ks Fuc (We) agrm w save indemnify Furl keep harmless the City of Cupertino against
O U imbitues, judgmenu, eau and upenus which may in any way same aBaiml said City
>. W in come stmee of the granting of this permit.
[� N AI'PLICANI'UNUP,HSTANIIl ANU WILL COMPI.y WITNA LN(rN�FC1IYT
U Zq#NS
I'UI/��I_oooa¢ USMATERIALS UISCLOSI/RE
Will thc applicant or fumrc Wilding occupant stent.handle haardom meltrid
az dcfimd by the Cumruno Mmucipd code. Chapter 9.Iz, and the Nedlb read Solely
Code, Section 255321U]
El yes ?No
Will ted applicmt m future Wilding occupant use equipment Or devices amen
emit 1p a ,ccs au conumioenb as defined by Ne Bay Arc. Air Quality Management
v ct]
❑Yes No
1 have rad hie dour pubertal, requirements Urdu Chanes 695 of dlt Cali.
factor Balth at Safety Code, Secrlmts 25505.25533 end 25530.1 understood! that if tie
M1uilding dors not purrcndy have a meant. thin it rs my mponsi)ylity w nasty the omupmh
Job Description
hay. FL. rIvvr /%ices IQ� O("1U"L1xi >, -
_5--S2—
MAR
—J 2
MAR 01 2000
3 (, /
il/Ti� encs/ CGpr
Re -roofs V
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.
Signature of Applicant
OFFICE
Date
All roof coverings to be Class "B" or better