00060094I` 1Q1'D1 D1°1ti1°" V PERMIT I CONTRACTOR INFORMATION: I I
BUILDING ADDRESS:
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under provisions of Chapter 9 b omntendng
with Section 9001q of invasion d of the Bu,i ne„ and Pro@,,ions Cdr, and my Ihrenec
Lin fail t'nrce and ctfiro.
icence Clan Lk, p
Dam Cotnromor
ARCHITIiCI"S DF.CLARNHON
I wWunlm,d my Dl.n, ,hall he toad as public record,
Licensed l'n,lcs,ional
I nard" it". �UNF.R-BUILDER DECLARATION
W'bar 1 um exempt from the Contractor's License lax for the
Ldlowing a a. (Section 91131 S. Hue nd Profen ms Gale: Any city o county
which regal a ".'it m aunemml, alter, int. . dcntolich, or repair may etniiurn
prior to iN kiancrec, also requires the applicant for such pannit to lila assigned statement
mat he is licenced pursuant ,, the pnnisinns of me Contractor, Licemv law (Chapter 9
(c ... Invoicing with Section 91XXI) of Dl vuinn 3 of the basin.., and Profusion, Cuda)
,n that ho i, exaapl doolott I and the hmia for the nII,,vd e,ctnpliod Any violatu,tl
of Section 9031.5 by may upplicmn lar n Is ria subjects the upplicamt to a civil penalty
of not more than Five hundred doll., (iNq).
C 1, as owner of the pmlmttY or my employees with wages as their sole campcncation.
will it,, the work, nod the nira,a— 1, nair mmadvd i adered for sale (Sce. 9043,
liueines and Profe„iun, Code:'I'he Co mefor', Llucnsc I.tlw does nal apply m In
coiner of property Who build, or improves thereon, and who docs such work himulf
rough his awn employee,. provided that such impmeemcm, am not intended or
offered for sale. If, howevcc the building or iniprnvement i, sold within one year of
mp,letion, lie owner.nuuder will have In, bunlan of proving that he ,fid tui mild or
improve Thr Parrow of culcl.
C 1, as no art of the mq,arr, . am eseh siody amaocting won licensed contractors la
construct the Prated (Scc. 9033, Emilia,, and Prnl'cs,mr, Cale:) The Conwcmr's
iev e Law doe tui apply Io an owner of property alta hooks or in,po es marean,
w,
m
and who e,nme,I for such pmjccu with v cimmmor(s) Iicel,ced purauunt to the
Commove, License Law.
e
❑ 1 nm exempt under See. . It X P C for this reason
Owner Daae
WORKER'S COMPENSATION DECLARATION
1 hereby affirm node, penalty of penury one of the following drelamtion,:
I I have mod will tnninmin a Cenlfmsc W Concent at salt' /inure foo Worker',
antpcnnntien, an provided for by Section 3700 of ilia, athor Code, for the
erfomtance of the work for which this permit is issued.
C I have and will maintain Worker's Canpemation Insurance, c required by Section
191111 or the lahor Cod, roti the p'It lmntrace of the work fit wh'mh die lwnlbl i,
isucd. My W'orker's Cotnpennaima Insurance carrier and Policy number arc:
Currier, Policy No.:
CERTIFICA'I'111N OF VXEMPOON FROM WORKERS'
C'OMPENSAT'ION INSUKANCii _
(Ibis section nerd nm he cnntplctad if the permit is foo one hundred dollar,
($100) of lass.)
I amil'y That m me lv,dor vac oI the work fur which Ihic,moil ie iswud. I
shell not employ any peryy any monam vn u, to become subject to Ilse wurkas'
Comaenmtion Iaww1(/ f ter ia.11mc
N(IIICIf'It1 N'YLICAM1Y. t IXtn85nn l`cTaa,moo osernmm. Ym, rob.
huomo subjcn to the Wndur's Cnm, its'nlion pnrvalnn, ul the Labor Curie, You nmsl
forthwith comply with such m vi%io, or his permit shall be dectned revoked.
CONSTRUCTION LENDING AGENCY
1 hereby uBlnn Ihul Them Is a con"imelio t fatting agency lb, the "Ifirrema,
of ho work lin which thin pcm,it is i„ued (Sec Px)9. Civ C.)
I<nder'n Name
Lemler', Address
I cant, Oen I hove tend Ibis uppllemio t and cam Ihm the above In rorntmion is
,onot. I agree. to ema IN cath all city and v...toy mdumove, and ,Tale Incas relating
Ice building corsmaal on, and hereby uuthariee represeamtives of this city,, cater upon
the abovementioned oopcny for im,ortinn purpooes.
(We) agree m save, indenotily and keep hunniac the City of Cupertino against
Iltihll'nies, judgment,., mus and espcnwc which Iney in any way accrue against ,aid
City in enmequence of the 6„ Ing of 11 spenalt.
APPLICANT UNDERNTAN .AND ��'tt�ILL COM PLY WITH ALL NON -POINT ISSUfd b
HA%ARDOUS AtA1 (RIALS DISCLOSURE
Will the applicant or future building occupant store or handle ha,mi rtlaterial
os debited by the Cupertino Municipal Cale. Chapter 9.12, and the health and Safety
Code. Seetlon 25532m)?
C Ycx C No
occupant use equipment or device, which
by the Bay Area Air Quality Management
C Ycs C No
1 huvc sad the Imrardous materials requirements under Chapter 6.95 of the
California Health k Safety Calc Sections 25505, 25533 and 255.14. 1 understand that
fthe holding due Intrmn11 It11
lenunt,thw a is my c,mr,ihililym maity the
'eapanl oil Ibe qt I hifh Tavl ha Incl prior to instance of n CrntFiente of
remcn
Orvupancr. T)0 6/l,r 1Zof
t
PI2RM I NO
00060094
APPLICATION SUB LATE
OF,/15/2000
SANTARY NO. CONTROL NO.
11UILUING I'IiRMiT (NPU
BLUE F.LIiCI' PLUMB MECH
Job Description
SERVICE PANEL
Sq. Ft. Floor Area
,J3JaJL r c.., r_n —Required Inspections
304 — ROUGH
ELECTRICAL
501. — FINAL
ELECTRICAL ENERGY
505 — FINAL
ELECTRICAL
Re -roofs
Type of Roof
Date
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 Date
All roof coverings to be Class •B+' or better