00040037CITY OF CUPERTII
BUILDING DIVISION
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PERMIT
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9 (commemivg
with Section ]000)ofDivision 3 of Mae Bmimad ssaProfessionsCode, aad my license is
to foil fore and efill �L
Liccnsa Cla _ ,C4 Us.0
Date s Conuacwr
ARCHITECTS DECLARATIO
I undenud my plans shall be used as public recalls
Licensed Pmfessiow
OWNER -BUILDER DECLARATION
1 hereby affirm rhes 1 am exempt from Mac Comuumrs License law for the
following masan. (Section ]031.5. Besimsa and Protests. Code: Any city or onsu ry
which requires a permit so com hum. atm, impress, demolish, or repair any atmmwe
prim to its issuance, afro ¢moires rhe applicant for such permit to file a signed mmmcnn
Nm he is licensed pursuant in Ne provisions of the Contractors License law (Chapter 9
(commencing wit Section ]000) of Division 3 of Ne Business and professions Code) or
tar he is exempt Morefrom and to basis for Me alleged exemption. Any viol -tion of
Section 7031.5 by any applicant for a Permit subjects this applicant to a civil penalty of
t mom than five hundred dollars (5500).
I, as own. athe property, or my employees with wages as Meir sole compersatim,
will dote work, anal rhe anucon, is am intended m offered forsJcIS. . 7066. Buaimss
and Professions Code: The Conuamwrs License law doss star apply to an owe. of
properly wba builds or improves duerenn, and who dors such work himself or trough
his own empleyas, pmvidd dual such impommmts ail Int Metaled m offered foe
We. If, however. the building or improvement is sold whom oro yearofcompletian, Me
wmrvbuild. will have o burden of proving tat he did not build or improve for Fm -
pore of sale.).
I, as owner of Me pmpeny, w exclusively contracting with licensed comvactors to
mostmctthe project (Sec. 7044, Business nal Professions Code) The Convenor's Li.
cense Law does not apply to an owner of propnny who builds or improves tenon, and
who contracts for each pirom. with a conVu em.) licorice pussmrs to the Codacwrs
Licanu Law.
1 ale exempt oder Sec. . B & P C for this moon
'awmr 6f/� A ee�iNS D.m
ORKER'S COMPENSATION TION /!/
1 herby affirm under penalty of perjury one of to followio8 des' aralian:
1 have end will matuin a Ccrlificnc of ConsenIto self -insure for Wohds Compen-
alion, as providd for by Section 3700 or rhe Labor Code. for the performance, of the
me for which this permit is ismce.
1 have and will maintain Wnrkces Compensation Insurance, as required by Section
370Dof Me labor Code, for Me performance of to work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
C.der: Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This action nece rot beco opleted ifduc prrrdrks foromhmakcd dollara(SI W)
or leas.)
I certify limit in Me performarce of Me work for which this pemut is issued, l shall
not employ any person in any mammy wase become subjccn to Me Workcn' Compen-
smion Laws mf Califoroia. Dere
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
hmnme subject to Me Worker's Compensation provisions of due Labor Code, you must
fonhwit comply wit such provisions or this permit shall d dared revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alRnn Mal Mere is a mmVuciian looting -gamy for Me perf—a
Me work for which this permit is issued (Sc. 309], Co. C.)
Leaders Name
Leders Adm,.
I certify that I have reed this application and state dot Me above information is
correct. I agree to Comply with ill city and county odbunces and cute laws misting to
building consvocuon, and hereby anhmiso rpmxenmives of this city to enter upon Me
eown. m.nmed properly for inspection pin -Fuses.
(We) agree to save, indemnify and keep harmless Me City of Cupertino against
Ilebilant.,,udgmcnts, emu and expenses which may in any way same against said City
m consequncc of Me &rode, of this permit.
APPLICANT UNDERS'EANDS AND WILL COMPLY IND If AL1. NON -POINT
I HAZARDOUS hi/fl'6RIALS DISCLOSURE / /
Will oapplicam or future building acupant atom or handle ous mmerial
esdefined by the Cupertino Muni tip .Cale, Chapter 9.12, mad the Healthand Safety
Code, Section 25532(e)]
Yes
Will to applicant or future building occupant use equipment or devices which
rhU as- o au conmmimnu or. red by to BaY Ara Air Quality Menegemenr
n
❑Yes No
1 have mad she hevrdous materials mquimmenss ad. Chapter 6.95 of the Cali-
fomin Beaty & safety Code. Scutiom 25505. u533 and 25534. I understand That if o
building docs not currently have a Bond. thou it is my mspomibifity in notify Me emupens
x;' 4 PERMIT NO.
CONTRACTOR INFORMATION U6 0 (LQ 0 ?J�
r SANITARY NO. APPLICATIONSUBMrITAL DATE
NIC CONTROL#
l22 yz!�S�/P �� ❑
BULDINOPERMI'rINFO'
,$iP i7e-iiae
Job Description
Sq. Ft. FloorArea
6 — 23'— o
'CLII VttI
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.
6 U
Sign�atl re of Applicant Date
All roof coverings to be Class "B" or better
OFFICE