00030140BUILDING DIVISION PERMIT
BUILDING ADDRESS:
LICENSED CONTRACTOR'S DECfARATION
1 he cloy aRrm Net 1 sm licensed uder provisions of Chapter 9 (commencing
with Section ]000) of Division 3 of the Business sed Professions Code. and my license is
in full force ad effect.
Lim. Clan Lid.«
Dam Co...
ARCHITECTS DECLARATION
1 undersand my plots shill be used as public becads
Liccom l Profonamml
OWNER -BUILDER DECLARATION
I hereby M. that 1 un ea,.pl from the Cm cactm's License Law for the
following mason (Section 7031.5. Business ad Profcniom Code: My city we county
which requirms a permit in com oro" alta, impmax, ncreA<moli,h, or rtpair anY swture
peiondo its issuance, also quire the applicant fa Formal Foal m file a signed...roma
Nu he is licensed pomwm m dm provisions of Ne Cmvstors License Law (Chapter 9
(commencing with Section 7M) of Division 3 ofthe Business arta Professions Code)or
that he is exempt th.cfrom ad the buia for the alleged exemption. Any violation of
Section 1031.5 by any.,diemu for a pemtis mbjmts the applicanno a civil pematty of
t more Nan five humrW dollars ($SW).
[] 1, a coca of the property, or my employees with wages as them role anpannumn.
wBl do thework. and the evucture is rot mumbldm oRemd for We (Sm. 1044, Biam es
ere Prorusiom Code: The, Contractor's License taw does rot apply to an comm d
property who builds or improves thenar, and who does such work himself or through
his bwn employ.,. provided than such improvements see not immded or offered for
We. If, however, sec building or improvemem is sold within one year of completion, the
ver -Wilda will have the burden of moving that he did n. Wild a improve for pur-
pose/rf We.).
MI. as owner of Ne Poor" • sm exclusively commismig with licensed Conmaon to
consumes the project (Sm. 7044, Business ad Professions Code:)1Ln continuities Li-
aise Law docs not apply to an owner of property wW Wilds or improves thereon, and
who tomenta for such projects wish a connacmrs) licensed pursuant to Ne ConvecmYs
License Law.
❑Iameac/mpt up S.. 9� B & P C for this mourn
none. /��f/� Dam T O
1 1 heathy Affirm under pmdty of perjury one of dm following declaatiom:
1 Wv<sd will sommuse n Cenlfica a of Comenuo self-houre for Wonkds Co.,..
anion, as provided for by Section 3100 of Ne Labor Cute, for the pertortrance of the
work f. which Nis pemN is issued.
❑ 1 have and will mainuin Workers Compensation Imucame, as emquucd by Section
3100of Nc Labor Code, fon din performance of Ne work for which this permit is issued.
My Workers Compemssian Insurance carrier and Policy numb. see:
Carrie: Policy N.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nand nes be completed if the Pmnit is formn hundred dollars (5100)
or len.)
I certify Ws in the perfmmance of the work for which this permit is immmL I small
non employ any person in any manner an as to become subject to the Wmkers' Compen-
sation Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, situ making this Cenifiom of Eaemption, you should
become subject to Ne Wockc/s Compensation pmvisme, of the Labor Code, you must
foMwith comply with such provisions or Nis permit shall be entered invoked,
CONSTRUCTION LENDING AGENCY
I mouthy aRtm that Nem is ....suction lending agency for the Portmnunc° of
the wink for which this permit is issued (Sec. W. Cr, C.)
Leder, Address
1 certify dist 1 have red this application and .am Nat Ne aWve of.d. is
corral. I agree to comply with all city sed county ordinances and vain laws mining in
Wilding construction, and hereby aothosire ecpremnwives of this city. mar upon use
above m ssiond property for impection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, mss and expense, which may in any way acme again. said City
in
nseq.nec of Ne granting of this permit.'
A11PLICAN r UNUFX I'ANDS iNdi1'ILLt�gNic],Y WI I H ALL NON-N)l N'I'
HAZARDOUS MATERIALS DISCLOSURE
Will ted applicant or furore Wilding meupam more or handle haescdous numsmd
as defined by the Cupertino Municipal Cod, Chapter 9.12, and the Hath and Safety
Code, Section u532(e)+ /
❑Yes [filo
Will the Applicant or future Wilding memento use equipment or devices which
anis Weardeus air commormants as defend by the Bay Arc. Ah Qudiry Mamgemem
riar.ia,
❑ Yes [}XR
I have read the huardous m.dds under Chapter 6.95 of the, Cali -
I. Health At Safety Code. Settiats 2$505. 25533 ad ]5534.1 udeastad don drive
Wilding does not emrejd,twe a umnt, that is is my awn biliry in notify the occupant
CONTRACTOR INFORMATION:
Z"()ti30'iC
SANITARY NO. APPLICATION
N/C CONTR
- BULDING PERMIT INF
00030/vn
Job Description
Sq. Ft. Floor Area Valuation p d
tem
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