00050004 CITY OF CUPERTINOPERMRNO. /
BUILDING DIVISION PERMIT CONTRACTOROR
INF .IVIA�IONI"1 (Do 0a�'O010,7"
PUILDING ADDRESS:
AI'PLICATIONSUBMITTAL DAT
WNER's NM
NIC
CONTROLM
ON`.' ElCIITEQIIACf
RULDING PERhfITINFO
CCZ
�00
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F LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby )).f Nati stn licensed under nd Proona of Cheaper 9(commencing p
with Souris]t100)of Division3ofthe BuaitKeaand Profession Cade,sed my licuseis
of
inamuc WrHecl t�IGL ��% �� ,P oDEG
y W U Littnm ClassLic.N
O gARCHfIF.CI'S DECLARATION
1 undeaund my Pl...bell bo used as public becads
R cic
R
K o Licensed Professional
qm_y • OWNER-BUILDER DECLARATION
1 hereby sRmr Out 1 am exempt from the Comracror's License Law for the
7=0 follwing reasons.(Section 7031.5.Business aW Profewima Cade:Any city m worry
im which earIm.a pamir m wmuuct,titer improve,darmiul,m tcpdr any awnwe Sq. Ft. Floor Area Valu•tion
prior to its i.auance,also tri the applicant fa such prom w file a sigmd statement , OOO w D
NIiamW
at he is pursuantNe
to provisions of contractors Contrars License law(Chapter 9
(commcncingwiN Section 10007 ofDivision]afNcBu.iau vel Prvfcoioo Codela epNN r Occupancy Type
But he is exemiatherefrom and the hour for the alleged exemption.Any violation of 3S`9A O� P Y YP
section 7031'3 by any applicant fora permit subject theapplicant to a civil pevlty of
not mom than rive hundred dollen(5500).
Lasnwnerofinepropertyormyemplayarwittwagecotheirsalecompositeon, Required Inspections
I do Ncwork,aedt:ric tmcismaintcWed Law
apply
to
and Ru oto,b Code:The Contractors..then ,keno law does rot apply to lf-throminsthrough of
progeny who builds or iv ided th Hereon,and who dere e,such wok intended
us of through
his own employee.,prmided Ous well mentis mcnt son na imended n offered for
uk.if.howe er,Nc erbuilding ur improvement Is told within ass ywof cons vefor the
-Wilder will have Ne burden of proving Nat M did not mild m improve for For-
pause
urpose of
I,as caner of the property ern exclusively contracting with licensed contractors w
convect the project(SIL.0(A4,Busing and Profeuions Code:)Tee Convector's Li-
cede law does ata apPly m im owner of property wed Wilds or insprovna there m,aW /
who coo."for such project with am
icmictor(s)licensed No..to the Camounc's
License Law. /
❑lamrs under .B&/PJCfar Nisrcuan O
W. Diaea' /r'1
s WO 'S SATION DECLARATION `/O
1 hereby� madndty e,peof perjury one of the fallowing declamiau:
❑1 have endwill maintain a CmiOcass of Convent to self-insum fm Wakees Compen-
trim,u provided for by Section 3700 of the Labor Code,for the perfornsoce of the
work for which this permit is issued.
❑1 have on,will..,auto Worker's Campers idmi Insurmce,o required by Secrion
3700of m,Labor Code,for the pr-fmmmKe of de work fm which this Permit is iunW.
My Wakces Compensation Initiatives carrier and Policy number art: '
Carver: Policy No.:
CERTIFICATE OF EKEMPIDON FROM WORKERS'
COMPENSATION INSURANCE
(This sterile need not becompluW tribe permit is formehunded dollars(SIM)
or Ins.)
I certify Wt in he pe,for aofthe it for which this permit is issued.Ishill
no employ any person in any manner so as to become subject o the Wadves Compcn-
wtion laws of Cdifomia.Dass
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Emmption,you should
become mbjecl to the Works.Compensation provi,ims of the Labor Code,you moat
fmhwith comply with such provisions in this permit dull be deemed rooked.
CONSTRUC`HON LENDING AGENCY
Q I thereby affirm NO Nee is a construction lending agency for the Perfooancs of
,Z Ne work for which this permit is issued(Sec.W.Civ,CJ
F. lander.Name
Z 7 lancer's Address
WI certify NN
at I have read u application and sass that the above inforrmttim is
C. wzcomet.l agree,to comply with all city and cwnty ordinances sed mass laws elating w
7 Z building....mctian.and hcuby suthorim mgessouives ofthis city.anter upon the
C.7 above-mentioned property far inspection purposes.
Ire. F,,, (We).gore m were.indemnify and kap hmnlecr Ne City of Cupertino spoof
Q (, liabilities,judgment,costand expanses which may in any way accrue again said City
in consequcnce of Ne Granting of din permit.
[� IL APPLICANT UNDERSTANDS AND WI LI.COMPLY Wn II Al.l.NON POINT'
sou :SEOUL
Sigtunnc of
ILK
A,OOF on t
HAZARDOUS MATERIALS DISCLOSURE
Willy te,Cupertino
upntor fume Wal Coc,Chapter
eoamd ehazardous maerid Re-roofs
o defined by rhe 32(s)?na Municipal Cele.CM1aptcr 9.12,reel Ne HCJN oil Safety Type of Roof
Celt,Section 25512(a)P YP
Ycs
Will tri
or orae Nilding occupant use equipment in&vice,which All roofs shall be inspected prior to any roofing material being
1bvWoasairconatniron4aadefinWbyNeBayAcaAirQudlryManagemcnt installed. If a roof is installed without first obtaining an inspection
JtvKt0 Yet I agree to remove all new materials for inspection. Applicant
ha a�dN haad� .maKrin erNiremwt W rGM1 pt AgSnfN e.i understands and will comply with all non point source regulations.
fmnu Health&Safely Code.Sections 25505,2533 and 25534.1 undmtW Out if the
b",doctors currently have.Kram,that'a is my responsibility to notify the acuprm
r tact w kcsuarcc of a Ct,0.faof Occupmc.
_ 5 Signature of Applicant Date
O i a DeK
All roof coverings to be Class"B"or better
OFFICE