06020127BUILDING DIVISION PERMIT
NAME:
3 o p LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Net 1 am licerucd under provisions of Chapter 9 (commencing
.m with Scetlon7") of Division 3 of NC Business and Professions Code. and my licamm is
< in full force and effect.
j Z License Class Lic.0
Dam Contractor
70) ARCHr1EC1-S DECLARATION
U I unlcrwnd my plans Mall he used as public records
g0(n Licensed Professional
y� OWNER -BUILDER DECLARATION
.� <2 1 hereby affirm that I am exempt from the Conume or's License law for the
COO following mann. (Section ]11313, Business and Profossiens Cash: Any city Or munry
$ 9! which requires a Permit m construct, altar, impmve, demolish, or repair any structure
prior ¢, its issuance, also requires the applicant for such permft to file a signed statement
ff G Nat he is licensed purmanun the provisions of the, Connector's License Law (Chapter 9
(commonring with 5ation]OBO)of Divbion Jo(the Business sodPmfutians Cotic)ur
Q that he u exempt therefrom and the bub fm the alleged exemption. Any violation of
Secdon 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not mom dun Ow hundred dollars ($50)).
❑ I.uowooraftliepmpwy,amyemplaymwiihwagauthe4mlecompensadon,
will do the walk end the structure isnot intended or offered for sale (Sec. 16th, Business
and Proposal.. Code: The Comancures License Law dm not apply to an owner of
property who buiIda or improm thermal, and whodoessuchwork himselfor through his
awn employee. provided that such improvements ora ant inched waffend for sale. IL
however, the building or improvement is mid within am: year of completion. the owner.
builder will have the burden of proving that he did not build or Impmw for purpose of
uic.).
❑ 1, as Owner of the property, am exclusively contracting with licensed ceranne ore to
construct the project (Sec. 7044, Business and Professions Cade:) The Conscrar's Li.
cave Law dm not apply to an owner of property who builds or impmm themun, and
whocontneta for such projects with a euntrnurts) licensed punuam to the Controls
License law.
❑ l am exempt vow Sec. B k P C far this
yank
nu [K�Q�-LVC DateZ Y M
I beroby a0hm under penalty of perjury am: of the following declan0ons:
❑ I ban and will maintain a Cenifrwteof Consent to self-insumforWmker'sCompen-
anon, u provided for by Section 37M of the Labor Code, for the Performance of the
work far which this permit is issued.
❑ I have and will maintain Walker's Compensation Insurmes, as requited by Section
37M of the Labour Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Inmtance carrier and Policy number art:
Carder: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becnmplewd if dm permit is i.e. bundrcA dollen ($100)
or less.)
I certify that In the performance of the work for which Ibis permit Is Wood. I Mail at
employ anypenon in any oras L —hS
en'Compewdon
Laws o(Califons.llMe
dec Work
ret (5FEL�_�Atfl
NOTICE
TO APPLICANT: If. afterCom making this provisions
of Exemption. you Mould
become subject y it Worker's Compensation provisions b the Labor Code, you must
.J O forthwith comply with such pmvtsinu or this permit malt he domed revoked.
Z 0 CONSTRUCTION LENDING AGENCY
F Ihareby aRnm that Nercuacd(Sex. M,Cing agency lot the Performance of
E
dm work for whlfll dd9 PLr11111 of located (Sex. 3M, CIV. G.)
W
Q LendorS Name
= z L<nder's Add.
() Q I cmrtify that 1 have mad this application and sum that the above Info m ation is
Dr l— correct T agree to comply with all city and county ordinances and sum laws missing to
QU building construction, and hereby authodm representatives of this city to color upon the
Irl Move -mentioned property for inspection purposes.
g� (We) agree to taw, indemnify and keep harmless the City of Cupertino against
s In liabilities,judgments, toss and existons, which may in any way acrnm against said City
C.: 7 in consequence of the totaling of this permit.
G7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE RATIOI�S� �� tv rJ
Stgnawrc pp cant/ ant r Daw{��tDam �tb
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accul mt Bow or handle hauNous material
as defined by the Cupertino Municipal Cade. Chapter 9.12. and the Health and Safety
Will the applicant or future building Occupant use equipment or devices which
emit huardou air conuml nu u deOned by the Bay Area Air Quality Management
District?
❑ Yea
Job Descrif
ADD 1/2 BATH @ (E) BATH &
REMODEL (E) BATH
• K
Issued by: J
Re -roofs
Type of Roof
rcnmu rvv' U 6 U 2 U 12
i &*X1104Q01
SANITARY NO.
Jai+Q9- 2006
Required Inspections
Date 7_ Z Z— U Z
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.
Signature of Applicant Date +,
All roof coverings to be Class "B" or better