00030096BUILDING DIVISION PERMIT
ING �
NtA/zl� f>A/O w
F LICENSED CONTRAC'TOR'S DECLARATION
C v G 1 hereby affirm that 1 un licensed under provisions of Chapter 9 (commencing
6rye with Seeion7000)ofDiviaion3of Ne u Busimssfife om Code,Wmylicemeis
.g in foil forceand 'Beet.
i ail i U usame Class U,#
is u Dau Cortacur
I- : C g ARCHITECTS DECLARATION
v� a S 1 understand my plans shall be used as, public rands
as
a a o C Li[vtaW PmfeuidW
v, OWNER BUTIMER DECLARATION
C Z < 1 hereby effism that I am exempt from the Connectoes License Law fm IW
O following ruson. (garion V31.5, Bmimeas and Prefd. Cade: My city ser county
3 $ which requires a permit to emenrum. Wier, improve, demolish, or .,it any snunure
prim tons i ..... ce, elm textures the applicant fm such pemut In File .signal sutemam
But he is IicemW pursumt to Ne provisions of Ne Contractors License Lew (Chapter 9
(commencing with Section 7000) of Division 3 ofthe ]NOR" tad Probations Code)m
that he is exempt theraf ern tad dna basis for the a1Rged esempeon. Any violation of
Section 7031.5 by any applicant fora permit veleynta the applicant to a civil penalty of
rot mo. Nan five hundred dollars 15500).
❑ by .won of dw mopenY.mmy employes with wage mNeinolc eompem.uon,
will do Nr wort, end the is Coue mm. License
or oRaM fm W apply . an omineof
and erty whom Col Thc Cm theta a Lnd w law docs Ind apply to if owner through
progeny who build, or improves such i tad who nts a such work himseR of edfee
his awn employees, provided Ni such mens I. old w art not in.Wfi ur offered fm
We.ILhdvever.11h Wildingorim offrmem Is coldwithinoneild of completion, the
owner -builder will have the When of provin8 Net W did net Wild a inprove for Pur
pose of agile.).
I, as owner of project
progeny, em exclusivelynd cmuesiong with Ii Thaw cmtraton to
once La Neal not pplyotaa,w,her of and Professions Code:)Thrves uarron. n
camslawdaor suchplytoan ownerofprcuo wild Wilda or aratavesthereon,and
who cono.es for with projaa withecontrecto ttn+W pumm�lw Nr Comramla
«nm law.
❑lam excmptundc a. .BAPCfor this reason
Owns / Data
ER'
WO KS MPENSATION DECLARATION
1 hereby affirm, nder penalty of perjury cm of the fallowing drelusliom:
m. as end will for by
a tion 37M of the Lam seRdnw. the
Wouress C of the
cation, u hick thi (pe mi Section 3700 of IM Labor Codc, for Ne pertomuae of the
work fix which ill aintaiis hired.
I lure and will maintain rpime Cover Of Or
Imuratwhi h rtquierd by Section
37000(thescow Corm. for Nco..earn of Ncwork for which Nis prnnin is iaauW.
My Workers compensation Insurance Gamier and Policy numM art:
Cartier. PION O
CERTIFICATE OF COMPENSATION
FROM WORKERS'
COMPENSATIONINSURANCE
(Thin.atinn need not be completed if Nepeemit is Torose hundred dellen ($100)
ml s.)
h, any Matin in myever., of Nework for subject
this themitisi rCmishall
not employ any penin in any comer m m to become mbjat to the wafters• Compen-
pTaws of Ca1i(omia Due
NOTApplicant
NOTICE TO APPLICANT. IL after making this Canons Of m Lamptim, you should
become a comb ro it Warkd. Compensation provisions of the L.bm Cade, you man
foMwith comply with such provixiom or this permit shall W deemed revokW.
CONSMUC K N LENDING AGENCY
Q Itmrby affirm that there is a commusuro lending agency for the perfamwce of
Z. y the work for which this permit is is all (Sec. 3097, Civ. C.)
Landers Name
7Landers Address
W I certify that I have read this application and ams than Ne above information is
d Iz corset. i agme to comply with all city and county ordinmses and stem laws awing to
r7 Z building comwction, and hereby euthoria.praaenmives of this city on enter upon the
f) O abovo-mam erect nursery (« inspection Purposes.
(We) agree w nave. indemnity and kap humleas the City or Cupertino against
C CJ liabilities, juigmems, erose and expenses which may in any way acrnu annual said City
} (gj in consequence of the grantingof Nis pemdt. -
t•w 0. AP%;PLICANTUNDIWNDSA ILLC Y I IN ALLNON-PoINT
U Z_
SOURCE REGUI S.
i .1 AF41115am,Cmurectur Dam
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future Wilding occupant store or handle harudons material
u defnW by the Cupertino Municipal Wr, Chapter 9.12, aid the Heald andSafey
Code, Section 255320
Cj Ye
Will Ne applicant or future Wilding ecu cant use equipment or devices which
eNil movement air contemn ares gefnW by Ne Bay Are. Ah Quality Management
Disme" .H,/,A/
❑Yes
I have rad the
harudcu+ material+ requi.manu miler Chapter 6.95 of Ow Cast-
Rome
HeaIN &Safety Code. Sections 25`M,, X25533 530.1 understand Out if the
Wilding doe tad currency toutq�anny^y�2, ounce Of. Cinit mIe of Neancy.
cuperm
of Ne.9ulmmenay)lin cors r f. Ccnificem of Occupancy.
CONTRACTOR INFORMATION:
)4,4 k4o &4,421d/fvl
NIC CONTROL#
Job Description
Area
Re -roofs
Type of Roof
al
MAR 15 2000 / 1
jf
All roofs shall be inspected prior to any roofing material being
installed. If a roof is Installed wi out first obtaining an inspection
I agree to remove all ne at s for inspection. Applicant
understands and jj11� pl t 1 non point source regulations.
2/'
Signata ofApp can[ Date
OFFICE
All roof coverings to be Class "B" or better