00040095BUILDING DIVISION PERMIT
(v kA6 o L'
NAME: , g c_ L I
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Nal 1 an, licensed under provisions of Chapter 9 (comrnmen,
with Section ]000) of Division 3 ofthe Business and Professions Code, and my license is
in full force and effect.
OWNER -BUDDER DECLARATION
1 hereby aKrtn that I am exempt, from Ne Contractors License Law for that
following assn. (Section ]031.5, Business and Professions Code: Any city or county
which requves a permit to camuuctalar. ar. improve. demm repair pair any more
prim to its iuume. also requires the apphcam fmsuch permit w fill. simm statement
that he is licensed pumait tolls, provisions oldie Convxtora U mse taw (Clanger 9
(commmming with Section 11)TBof Division 3 of the Busircv and Prolamines Code) in
that he is exempt therefrom and the basis far Oe alleged <,unin, man. Any violation of
Section 1031.5 by any applicant for a permit subjects doe applicant to a civil peWty, of
not more than Eve hundred dollers (5500).
I. as owner of the property, or my employees with wages as their sole compensation.
will do Ne work, and de ameore is nm 1mi nded moffered for We (Ser. 1(160, Bun
ucss
and professions Cads,: The Contractors License law does not apply to an owner a
property who builds or improves thereon, and who does such wort himself or through
his own employees, provided that such improvements ate not intended in offered for
We. lf, however Nc building or improvemut is sold within tone yea of completion, rha
wnsnbuilder will have the burden of moving Net he did not build or improve for For,
pose of ads.).
1, u owns, of the property, am escluaively convecting with licensed cMVYA010 to
conswm Ne project (Sm 1060. guineas and Professions Cade) the Comnemra Li-
cense law does nut apply to m awnsr of property who builds or improves thereon, sed
who contents for such pmjmu with aconrmtm(a) licensed pursuant to the Conlmctors
U.nse Law.
❑ 1 em ezcrl�[?Mer Sa. . B A P C for this muton
Owens - — sate �Fa.a—s-uxl
WORKATI
WORKER'S COMPENSATION DECLARATION _ L`'�
(- I hereby affirm under poetty of perjury one of the following declarations:
❑ I have end will maintain acenificate ofcamut to W eimure fmworkeesCompete
,anion, ea podded in, by Section 3100 of the tabor Cada, for the prRorem. of the
work for which this permit is issued.
L have and will rom uin Worker's Compensation Wuenow, , as requited by Section
3100 of the labor Code, for the porronname of the work for which Nis permit is isoM.
My Worker's Compensation Insurance carrier and Policy number are:
Cartier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ronin need not becoorplened ifnhe mea is for one hundred dollen 15100)
or len.)
I certify Nat in the perfornmor f the week for which this pemtil is issued, Ishall
nowmploy any lemon in any mmnsr, aro .,in becorne subject o the Workeri Conmon
.tion laws of Celifomia. Dau
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Escmprion, you should
homme, subject to the Workers Compensation provisions of the labor Code, you must
foMwith comply with such provisions or this permit shall be doe ad revoked.
CONSTRUCTION LENDING AGENCY
I hemby afBmt than Nen is a construction lending agency for thc performance of
the ..it for which this permit i, noted (Sec. 309T, Ci, Q
Landed, Name
Lenders Adders,
I certify Na 1 have read than application and sone Nate above infomstion i,
correct, l non, to comply with ell city and coumy ordinances and Rum laws miming to
building construction, end hereby authorim repremeutives of this city to enter upon the
above-meminned property for inspection purposes.
(We) agree o Rave, Indemnify end keep hsrmlcus the City of Cupertino agamst
habilitics,judgmenu, costs and expenses which may in any way accrue against mid City
in con rqucnm of the granting of this pemit.
APPLICANT UNDERS rAN US AND WILL COMPLY Wit If AI.I. NON -PI )INT'
HAZARDOUS MATERIALS DISCLOSURE.
Will thc applicator or from budding occupants mem m handle hseNous masuu
RE defined by the Cup,runoMrnici I Cod,. Chapter 9.12, and Ilse HWth Rod Safety
Code. session 25532(m?
(]Yes No
Will the appllcrt in room bun rte occupause e,uipmsm or device, which
nit ha>'alloua b conumirenu as final by thnt e Bay Arne Air Quality Management
arihc?
OYER No
1 have real the hasardws mammals requirements under Chapter 6.95 of the Cali.
form. Meakh & Safety Code. Sections 2550.5, 25533 and 25536. 1 understand that if the
building does not currently have a tenant, Naz in is my responsibility to notify the occupant
ofth—immemg whidh mum be met.6,1. - - em0clupncyt
SoLrro Cowswcri
5 ct -DIU is cath 5t>2c15 r—
Job Description
-5'i37
I
000g00gl
m
Re -roofs
Type of Roof
LimK
J
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
u stands rad will comply with all non point source r gulatlons.
Li
Signature of Applicant Date
OFFICE
All roof coverings to be Class `B" or better