00040181BUILDING DIVISION PERMIT
Q S; — 2G5 /
ARCHITECUENGINEER
�OC
Q�'tl
LICENSED C'ONTRACrOR'S DECLARATION
0 z : 0 I he rby affirm that 1 am licensed under provisions of Chapter 9 (co.nong
i- with Section]000)mfDivision 3 of Ne Business and Professions Cork, and my license is
$ in full force end ell G 64 ; ✓J
0w o.t�nae cl.n �— ��. �.s e-r�—v--
H O g ARCHITECTS DECLARATION -
E vW 5 1 understood my Plans shut W mud as public oncOrds
K
a a licensed ProfeuiatW
W OWNER -BUILDER m Ce Contr, ON
1 hereby ammr the 1 1. exempt from Nc Contns Coe License Lew forco the
or F following nam.. (Section ]031.8 Business and ere. Professions Gds,: Any city or county
c. 3 which requires a Permit m comwn, alter, improve. hmotish, m span tiny awems
perm to its issuance. use requirto Ns, applicantfmsorh pamitmfileesigord ataemcnt
shatWiscirig with
loth[pmviimsof theCmvatns; Idttnrelaw(Chapter ,
(hat hei exewideSaGonorund cf Division3 ufrheeuei.e. and Po Aciy mCadc)m
Wt he is 31.5 b any
and dm basis for be alleged nemption. Any violWm
Wt ion ]031.5 by any appl¢mt fm a permit mbjam the applicant to a civil
Wt mosnm
Bvc hMted dollen ($5N).I. as ow.r of the property. mmY employees with wagcnu Weif aolec penaauon, '
will dothewoh, and the awdusisnm inrcndedm aw'donorole(S7.'-I uuncas
and property
whons Code: IM Contractor's radLicense Law seri ant apply ro ren ow
his.. who Wilda or impmvu t inch i and who don such wort Aimselr a through
nn own however
the provided r i such meet is sold a me o intended a Offered for
ole.r- howercnted Wil dingorimptostamissoldwithin oorYear ofcotrml, for he
owner -Wilde will have the When of proving Net he did not build m improve for pur-
er of ole.).
I, as Owner of the property, mer exclusively convecting with licensed] contractors to
cormtnct Ne project (Sec. 7000• Bushes, and Profeoinm Code:) The Connector'. V-
cemc law does not apply in an owner of pmperty who Wilda in improves thcrcoa, and
who contracts for melt projects wish a contractorfs) licenced pursoaot to she Connec'tor'
License law.
❑ IM excm%under Sec. . B & P C for this mecum
Owner Dao
WORKER'S COMPENSATION DECLARATION
1 hereby •?rat under pr ally of wpiry arts, of the following declmetio e:
❑ IhevcaMwalmainminaC nmcmeofComenttowif-imumfmwo esCompen-
ratio., m pmvidM for by Section 3700 of the tabor Code. for the Perfomaore of the
wk f this pemus is issued.
m eve and will maintain Workers compenmtion Insurance, as mquircd by Section
3700of Ne Labor Code, fm the performance ofthv work for which this permit is issued.
My IN Cyt/ s Cy� o n { urance terrier and Policy qumbcraf ss 8
I�rtieS�B1-/er/!I'�A-/es...f Policy No.: G_�JW?
CERTI�KUON FROM WORKERS'
COMPENSATION INSURANCE
(This sari. mad nm becompleradifde pclmit is fororehuedred dopes (SIM)
m less.)
1 certify Nat in the performance of rhe work for which this peanut is ismod, l shall
nm employ any penton in any manner an, as to become onjo rto the Woheri CmmPen-
Union taws of California. Date
Applicant
NOTICE TO APPLICANT: If, e(tu making this Cenifins of E.emptim, you shmld
become subject to the Workers Compenotion ptoviu n, or the Labor Code, You must
fnMwith comply with such pmviuons or, this Permit shall be deemed nevolood
CONSTRUCTION LENDING AGENCY
I hereby affirm in. them is a croshucd.n lending agency for the perfmmance of
%. the work for which this pemtil is Issued (Soc. 3097, Civ Cd
Lender, Name
7 alders Address
Lr]1 certify the i have noted this application aMwNa
,c don e bve oinfo. 6. is
6. 0 conal. I agree to comply with all city and spumy ordiweea and etas laws .Icons.
.7 Z building construction, and hereby luthens representatives of this city m enter upon the
U O above-mentioned Dropeny for inspection Purposes.
Lsa t y (We) agree m save, indemnify and keep harmless the City of Cupertino against
1,•) lishilons.judgments, costs and expenses which may in any way aeons against said City
in emsequeore of Ns, gsnd, of this permit.
[� d APPLICANfr UNDERS17AND' UW;t%?LOMFI.Y WI TH -1J. NONPOINT
U z 5 UNCF, RI:O t 1O�
Sie^a A i' onDam
HAZARDOUS MATERIALS DISCLOSURE
Will the a C.,ecl m (mute il-1 Co «cupati senor handle hazardous d Safety l
m defiord DY the Cupudno Municipal Cede. Chnpw 9.12, and N< Health orb Safety
Code. Section 2353](a)?
❑Yrs ❑No
Will the applicant ter future Wilding occupant use equipment or devices which
emit hicAndmin air commitments a, defined by the Bay Arca Ah costly Manalconot
District?
❑Yes ❑No
I hove read the noondoe, numrials mluiremena under Chapter 695 of the Cali.
Comma Health & Safety Code. Sections 25X)5. 25533 and 15530.1 understand that if the
Wilding dors nm cutremly have a meant. Nat it is my rnpornibilay to moony the occupant
Of the rcqubamenta which muse he met prior m iouan e, of • Cenificate of Occupari.
owner or audenaed agent Dau
/j wlfi�wJ 1n1�1 p1 /��a/v SANITEl
Job Description
(fox,at-a' � /oac-'� / &'a
oil,
T t
V' T
03 i
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