00050087BUILDING DIVISION PERMIT
;ERAS NA MB: CONTROLM
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7HITECr1FNGINEER I BULDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I ase lI[enaed under provisions of Chapter 9 (emmeoeing
withSoclum 7000) of Division 3 of Ne Business and Profeviom Code, andmy license is
in full force ands1.
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liscnsed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Prolandona Code: Any city or comm,
which roquires a Permit to construct, alar, improve, demolish, or repair any nN91ure
prior to its issuance, also requires she applicant for such permit W file a signed narnent
that ho is licensed purauanl to the provisions ofthe Contractors License law (Chapter 9
(commencing with S«von 7p4)(1) of Division 3 ofilme poison and Preffassions Cade) or
that he is exempt therefrom and the basis for the alleged axemption. Any violation of
Section 1031.5 by any applicant fora permit subjects the applicant m is civil penally of
not more Nan five hundred did. (3500).
Q I, as owner of the property, or my amploycea with wag. a Nei no le compenseuos,
will this the work, and Ne almccom is era ioterWW m offm d fm We(S.,1041. Buri..
asmd Portland. Cade: IM Conuaetor i License law does not apply to se weer d
Property who Winds or improves cement, and who dors tach work himself m through
his own employers. Provided the such impnav<rneqts am not intended or offered for
sale. If, however. the building or improvement is sold within one yearmci mpletion, dm
owner -Wilder will have the burden of proving than he did not build or improve for put.
pose of.I.J.
I, in Wirer of the property, ase exclusively contracting with licensed contractors to
Wim liar, Ne From, (See 7644, Buain.s and Professions Code) The Conuecmel Li.
cease law does and appy to an owner of property who builds or improv. Ih.aan, and
who eoobacts fm such projects wish a cremations) licensed Wrseenl in the Canvecmrs
License law.
1 an exempt under Sea .B&PC for this rtuon
Dole
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WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penally of pmjuy ore of the following declarations:
❑ 1 have and will maintain Cemp.r of Consent to self -inure for Workers Counter.
satins, u provided fre by Section 3100 of the Labor Code. for the performance of the
work for which this pecrul is casted.
1 have and will maintain Workers Compenuton Insurance, in required by Section
3100of cc Labor Cade, for the performance of the work for which this Permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier: Policy No:
CERTIFICATE OF IDUMI'DON FROM WORKERS'
COMPENSATION INSURANCE
(This section oaedna Eccompleted ifllme permit u froom hundred dollars (SIM)
or less.)
1 certify that in the Performance of the work for which this pemut is issued,) shall
or, employ my gersoon in any Tampa_ at In became auhleclo de Workers C—Pen-
NOTICE TU APFLICA : If, ager snaking this C Rifi [�of Exemption, you should
bmnmc subject to IIB Workcres Coenpenuti0n provumns of the labor Code, you must
forthwith comply with such provisions in this permit "I be decreed revoked.
CONSTRUCTION LENDING AGENCY
QI herebyuRlm On Nem its mmtmcuon lendinpegency for the performance of
Z Ne work for which this permit is issued (Sm. 3097. Civ. C.)
E.. Leaders Name
�i > Landers Address
W1 costly dor 1 have need This application and awe thal the above iNomulion is
1 z Co... I agree to comply with all city ncou
al nt' ordi..nd aatm laws sluing lin
7 7 huilding connmcuon, and hereby unhurce repacaenwiv. of Nis city an enmr upon the
�% Q above-mentioned paopeny for inspection purposes.
❑. H
(We) agree to save, indemnify and keep harmless the City of Cupertino against
V liabilities, judgmema, cents and aspensal which may in any way accuse apart and City
>., rt') in consequence of the gunung of dus Permit.
AP ANf UNDERSTNDS AND WILLCOMPLY WI III ALLNON-YOIM'
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_5-12- On
Sigammm of ApplicrntiC.mosc / Dole
HAZARD RIALS DISCLOSURE
Will Ne applicant or future Wilding occupant sem or handle haemdous martial
as defined brine Cupertino Municipal Code, Chap. 9.12, and the HdN and Safety
Code. Section u532(07
❑Yes C] No
Will the applicant m future building occupant use equipment or devices which
i haurdaus air conwamants as defend by Ne Bay Asa AU Quality Management
RVICIi
❑Yes [7 No
I have sad the hasardws materials ials requirencnla under Che6.95 of tho Cali
fame Health & Safely Code. Sections 25505. 25533 sed 25534.1 understand thal if the
baa) ', duct era currently have a tartan, Wt it is my rnpumibiliy to notify the occupant
eT dsc neyuiremmu which must be met pia to iauaaace of a Cenificete MOccuparcy.
Job Description
A-j� A -DD , ��,,2�, 0#74
AZ> Vo/T Cir-c.�lT 0*1?- Al(f-(#0 4*1
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