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BUILDING DIVISION PERMIT
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CONTRACTOR. INFORMATION:
I a,vq-�ra2- P J3 A
elz o k 60-0- /9'
LICENSED CONTRACTOR'S DECLARATION
I hereby alrrrm thm l w licentW Mees provisions of Clue'. 9(com .1., Job Description
with Section 7000) dDivision 3 ofthe Business W Professions Code, and my license is 7
LDnefmm`df;C
0777 /o o k
Con
DELL
ARCHDECL
ITECTS ARATION
1 understand shal
nd my priml W mW m ptmk a«dr
licensed Pmre oinw
DW NER-BUILDER DECIARAnON
1 hereby affirm Chet T ern exempt from the Conuacme, License Law for the
following moon. (Section 703 IS. Business and Prokmiona Code: Any city or county
which requires a ponfut to construct, Wer, improve, demnlirb, or repair any mucnue
prior to its issuenm, also responses she applicant For such permit In flea signed Itamm n.
that he is licensed punont to Ne provisions ofthe Conor Mr. License law (Chapter 9
(commencing wish Secuon 7000) or Division 3 ofthe Business and Professions Cedelea
that he is eacmp' therefrom and um buil for the alkged exemptim. Any violation o1
Section 7031.5 by any eppfcant for a permit mbjecs the epplic. M s civil penalty of
not mom then flue hundred dollar (5500).
1, as owner of the propert, or my employcca with wages as their ..In compensation,
willdothcwork'and Neewcture is trot intended or offered for I. (See 7044. Business
and Professor m Cade: The Contratofs License law docs not apply to an owner a
proper, who builds or im ouv<s thereon, send wW duce such word, herself or enough
his own employees. Provided out such improvemann me set inanded m offered for
sale. If, however. the building or improvement is sold within one ym of complmim, the
owner -builder will bre the burden of proving that W did not Wild in improve for pur-
pmc of Rel,t
1, as own, of the property, sen exclusively contracting wish licensed contractors to
contoua she project (Sw. 7044, Business and Professions CodeB The Conoadoe. Lt.
cense law does not apply to an own, of property who builds or impmvc, thereon, and
who convects for such projects with a convactafR) licensed pursuant to the ConUamts
Liccnu law.
❑ 1 am exemptunder Sec. . B & P C for this mason
Owner Dam
FYI
WORKER'S COMPENSATION DECLARATION
�avherebyillnnnunder penalty ore perjuryoneofthefollowing odrees Co
fIlove and will maintaineCeni 37M of the I-
uo self-insor for Wor4ete Compery
otion, o provided for by Section 3700 of she labs Cade, for tW pedomunce of tic
k fy/which this permit is issued.
t�,Yheve end will nounno n Woakcer Compen uskis Insurmrce, as MspuMA by Section
370Oof the Labor Code, for the Perto. of the work for which this permit is boom.
My Work<Is CompetWetInsurance w and Polity tie.', r
Cama: an. Policy ticr.
T TIR ATEOFEXEMPTION FROMW KERS'
COMPENSATION INSURANCE
(This Me rim need not be complemd if the perfect is forest, hundred dollen (SIM)
or km.)
I codify the, in the peif.. of the const for which Chia pemut is issund. I shell
not employ any pemon in any maoner so as to become subject to thc Wooten' Compcn-
satlon Laws of Califomia. Date
ApPlicm'
NOTICE TO APPLICANT: If, after meting this Certificate, of ERemWm, you should
Wcomc wbjwt m the W. k s Compensation provisions of the LUWr Code. Y. must
foMwith comply with such provisions or this permit shell W deemed Invoked.
CONSTRUCTION LENDING AGENCY
1 Wreby afGmr that dote is a construction lending agency for the performance of
the work for which this poesch is issued (Sec. 3097, Civ C.)
Lender's Arline,,
I certify that 1 have read this application and mile that he above infomtation is
arta 1 agree to comply with ell city and county mdimncea and new laws selecting to
Wilding construction. and hneby mthonu rtprtarnutivce of this city re enter upon she
above-mentionnd pmpnty for inspection purposes.
(We) agree to neve. indemnify and kap harmless the City of Cupertino against
liabilities,judgments, coats aid expenses which may in my way me me against said City
in
consequence a the grantingper
of this mit.
AP9tlN N IINDI:RSTANDS AND W II.I.L )MPLY W I'I'II AI.I. NON-POINI'
HAZARDOUS MATERIALS DISCLOSURE
Will the mplieans or future Wilding Occupant store or handle harard. material
of defined by the Cupceino Municipal Cade, Chapter 9.12, and the Health red Safety
Code. Section25532(.)?
❑Yet e�
Will the applicant Or future Wilding Occupant use equipment or devices which
emit heaardous sit comminenta a fined by the Bay Aro AG Q dity Mmme
agem
l suit'?
i' ❑Ycs No
I have mad the harardws me'erials requirsom. took, Chapter 695 of the CW.
forma Health & Safety Code. Senium 25505, 25533 and 25530.1 underr that if use
buildingf9gma cmrtnrly have a t mm, th.Q is my msporribiliry, to notify the Occupant
agent
met
Sq. Ft. Floor Area
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.
Signature of Applicant
OFFICE
All roof
Date
to be Class "B" or better
rs:nmll nil.
006q
000 (
,NITARY NO.
APPLICATIONSUBN
I y'/1—�0
IC
CONTROLg
97
BULDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
I hereby alrrrm thm l w licentW Mees provisions of Clue'. 9(com .1., Job Description
with Section 7000) dDivision 3 ofthe Business W Professions Code, and my license is 7
LDnefmm`df;C
0777 /o o k
Con
DELL
ARCHDECL
ITECTS ARATION
1 understand shal
nd my priml W mW m ptmk a«dr
licensed Pmre oinw
DW NER-BUILDER DECIARAnON
1 hereby affirm Chet T ern exempt from the Conuacme, License Law for the
following moon. (Section 703 IS. Business and Prokmiona Code: Any city or county
which requires a ponfut to construct, Wer, improve, demnlirb, or repair any mucnue
prior to its issuenm, also responses she applicant For such permit In flea signed Itamm n.
that he is licensed punont to Ne provisions ofthe Conor Mr. License law (Chapter 9
(commencing wish Secuon 7000) or Division 3 ofthe Business and Professions Cedelea
that he is eacmp' therefrom and um buil for the alkged exemptim. Any violation o1
Section 7031.5 by any eppfcant for a permit mbjecs the epplic. M s civil penalty of
not mom then flue hundred dollar (5500).
1, as owner of the propert, or my employcca with wages as their ..In compensation,
willdothcwork'and Neewcture is trot intended or offered for I. (See 7044. Business
and Professor m Cade: The Contratofs License law docs not apply to an owner a
proper, who builds or im ouv<s thereon, send wW duce such word, herself or enough
his own employees. Provided out such improvemann me set inanded m offered for
sale. If, however. the building or improvement is sold within one ym of complmim, the
owner -builder will bre the burden of proving that W did not Wild in improve for pur-
pmc of Rel,t
1, as own, of the property, sen exclusively contracting wish licensed contractors to
contoua she project (Sw. 7044, Business and Professions CodeB The Conoadoe. Lt.
cense law does not apply to an own, of property who builds or impmvc, thereon, and
who convects for such projects with a convactafR) licensed pursuant to the ConUamts
Liccnu law.
❑ 1 am exemptunder Sec. . B & P C for this mason
Owner Dam
FYI
WORKER'S COMPENSATION DECLARATION
�avherebyillnnnunder penalty ore perjuryoneofthefollowing odrees Co
fIlove and will maintaineCeni 37M of the I-
uo self-insor for Wor4ete Compery
otion, o provided for by Section 3700 of she labs Cade, for tW pedomunce of tic
k fy/which this permit is issued.
t�,Yheve end will nounno n Woakcer Compen uskis Insurmrce, as MspuMA by Section
370Oof the Labor Code, for the Perto. of the work for which this permit is boom.
My Work<Is CompetWetInsurance w and Polity tie.', r
Cama: an. Policy ticr.
T TIR ATEOFEXEMPTION FROMW KERS'
COMPENSATION INSURANCE
(This Me rim need not be complemd if the perfect is forest, hundred dollen (SIM)
or km.)
I codify the, in the peif.. of the const for which Chia pemut is issund. I shell
not employ any pemon in any maoner so as to become subject to thc Wooten' Compcn-
satlon Laws of Califomia. Date
ApPlicm'
NOTICE TO APPLICANT: If, after meting this Certificate, of ERemWm, you should
Wcomc wbjwt m the W. k s Compensation provisions of the LUWr Code. Y. must
foMwith comply with such provisions or this permit shell W deemed Invoked.
CONSTRUCTION LENDING AGENCY
1 Wreby afGmr that dote is a construction lending agency for the performance of
the work for which this poesch is issued (Sec. 3097, Civ C.)
Lender's Arline,,
I certify that 1 have read this application and mile that he above infomtation is
arta 1 agree to comply with ell city and county mdimncea and new laws selecting to
Wilding construction. and hneby mthonu rtprtarnutivce of this city re enter upon she
above-mentionnd pmpnty for inspection purposes.
(We) agree to neve. indemnify and kap harmless the City of Cupertino against
liabilities,judgments, coats aid expenses which may in my way me me against said City
in
consequence a the grantingper
of this mit.
AP9tlN N IINDI:RSTANDS AND W II.I.L )MPLY W I'I'II AI.I. NON-POINI'
HAZARDOUS MATERIALS DISCLOSURE
Will the mplieans or future Wilding Occupant store or handle harard. material
of defined by the Cupceino Municipal Cade, Chapter 9.12, and the Health red Safety
Code. Section25532(.)?
❑Yet e�
Will the applicant Or future Wilding Occupant use equipment or devices which
emit heaardous sit comminenta a fined by the Bay Aro AG Q dity Mmme
agem
l suit'?
i' ❑Ycs No
I have mad the harardws me'erials requirsom. took, Chapter 695 of the CW.
forma Health & Safety Code. Senium 25505, 25533 and 25530.1 underr that if use
buildingf9gma cmrtnrly have a t mm, th.Q is my msporribiliry, to notify the Occupant
agent
met
Sq. Ft. Floor Area
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.
Signature of Applicant
OFFICE
All roof
Date
to be Class "B" or better