00040010iW
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR','INFORIVIATION:
UILDING ADDRESS:
200zS A! N/J 5 C7Gs4Pl Qm/A4K ] *51*kle ANIT
wNER'S NAME: ," `� A N ' --a•Ms l
CA/ / NIC
'
H:: 3-06-ia+a' 7—/� ❑
<CCHITE-CI'IE/µ/GGIINEER
N,/A
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under pmmWints of Chaplet 9 (commencing
wish Section T880)of Divisim3ofthe Busimna P feaoions Cadr,and Yliccmcis
in full form and affect. s
Licenrc IiaN
Date Convenor
1 ,eARCHRECPe DECLARATION
m -y lans shall W used u public rccads
Licensed PmfcssimW
OWNER -BUILDER DECV.RATION
1 hartby afftm that 1 am exempt from the Contractors License law for the
following reason. (Section 703 1.5, Boomers ad PmRaaiov Cuda: Any city a rnunty
which requires a pormit to consul dor, impmve, demoliN, or o pass any euucmrt
prim todsissuer., also regain, Un applicant for such Pr 'to file- rill aummem
On W is li.md purnal to the pmvidom ofthr Connectors License law (Chapter 9
(comm mol with Section 708p)of Division 3 ofdu But. aha Pmfnsiosu Code).
Wt he is exempt thmefxem ad the Wais for the dleged exemption Any violation of
Section 7031.5 by any applicant for a Proof subjects the applicant to a civil parody of
not mom than f yr hundred dollen (5500).
❑ I, as Dourer of Nc ptopeny,mmy cmploy<n with wa%esu thrinole wmpemtimn.
will tlo Nc wok,ad Neawnurc rat h Immose oscalfor We(Sec.]0f4.owner
and Fry who
Code: The Contractor's Lime Lew docs rat apply to lf owner of
property wlro builds ;e improve thatch, ouW who mm each work himself of through
his own owevereca ptnvidd Nat such improvements are not iyear od m oHcrd for
cele. If, mower with building m improvement Is sold within one year of completion, thr
nrof Weer will ha. Or burden of proving that he did not Wild m improve fm For-
From
r
pose of We.).
h as awncr of the Sax, property, am exclusively confessions fthCool licensed fficCconuacmn t.
cmuwn dpmjat(Sec.o an ownBuser
ofsadrly who onsWi Cdr:)theC thermors V.
cense law alas ret apply to is owner of propmy who build. or .a, in
Contractors and
wla crowns for son prolecu with a contmmor(sl licensed punuem m the ContramA
License Law.
Ism exempt oder ia. . B 6 P C for Nis wan
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby alarm seder penalty of perjury ons or the following declarations:
Ll 1 hove and will maintain a Certificate of Consent to self-insum for Workeb Comprn.
Finn, as provided for by Section 37W of Ne labor Code. for the perfomuna M the
Ko k for which this permit is issud.
1 Wve and will mountain Worker's Compensation formal as rmpuind by Section
3 often Labor Code, fm do, per(omtmne of tho work for which this permit u ural
Ewe,My Wor <rsand FROM WORK iR U,$
o" ar��•Policy No: Y
CERTIFlCA OFEXEIPENSAn Ni NPR NCS iRS'
COMPENSATION INSURANCE
(ren sectio red not he completed Al Permit in f«ore renamed dollma (Slop)
Or Ires.)
I.nify that in On pedowence of the work for which this permit is issued. I shall
not employ any in Y. nery=o on o no, Workers' Compen-
sation Law,
Applicant .f.a,./7!Z
NOTICE LIC : If. aha making tri, CrOficmm�.nvrmpdmn. you should
haeme subject to the Worker. Compensation provisions of thr Labor Code , you must
faMwitn comply with such pmHsimas in Nis permit,hdl W deemed revokd.
CONSTRUCTION LENDING AGENCY
I hereby .lion thin there is a combol lading agency for the Perfamal of
the work for which this Wwit is issad (Sec. W. Civ. CJ
Leaders Name
Lenders Addre.
1 certify thou 1 have orad the application and store that Ne above irdomution is
Tact. I ague to comply with a l city and county ordinal and sun laws relating to
building construction, and hereby audanim representatives of this city to enter upon the
above-memiond property for inspection purposes.
(We) egone, to save, indemnify and kap hmmlesx the City of Cupeniat agAmot
liat judgrmnts,amu and nprose, whichtoy in any way mom agd. said City
in mosequeacr of the 8ruffng of this permit.
APPLICANT UNDERNTA NDS AND WILL COMPLY W ITII AL1, NON -POINT
SOURCE RED ULA'I'IONS.
SigmtunefApplim.UCmuaxhm Date
HAZARDOUS MATERIALS DISCLOSURE
Will On Applicant or fame budding umupent store rehandle notorious maund
as depend by the Cuperdm Municipal Code, Chapter 9, 12. and the HWth end Safety
Code. Section 25532mo?
❑Yeso
will do applicant or future Wilding recall use equipment of devices which
cats hassrOms au contamimnu as deBnd by Ne Bay Ana Air QW iq Management
District?
C] Yes
I have mad On hersNwa materials m luarmenn all Chapter 695 of the Cdi-
fan!B�de" Section ]3585. 75533 and ]5534.1 udmund dun if the
builYantofn muse rte met w aueme or a can Lie Oce
Owner or audadzd agent f Dan
Job Description
b q (0O
Sy. Ft. Floor AreaI J /� Valluuatiion Q
_0
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
All roof
OFFICE
Date
to be Class "B" or better