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BUILDING DIVISION PERMIT
BUILDINGADDRISS:
22 yoc -5&om f�lrG
bio
2ao 5
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that, 1 am licensed under provisions of Chapter 9 (commencing
wide Section' 1000) of Division 3 of Jae Business it Profeuior, Code, sd my Hama is
in full fora and effect.
License Class Iic.0
ARCHITECT'S DECLARATION
I understand on, Pim shall be used is public mix ds
Licensed Pmrenieml
OWNER-BUR.DER DECLARATION
1 hereby affirm that I am exempt from the Commoners License Law Inc the
following ruson. (Section W31.5. Busicess and Profwiom Code: Any city or wuoil
which tcaui¢s a permit m construct, alcor, improve. demolish, or repair any a -
prior to its isauma, also squires the applicant for such Permit m fit.. sigrd sutemem
the he is licensed pursuant to the pmviaions of the Contra's- Licmu Law (Cluptcr 9
(commencing wide Section )000) of Division 3 of the Business and professions Code) a
Jut he is exempt therefrom ad the Weis for the alleged exemption. Any violation of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of
out more Nan rive hundred duller ($500).
E] I, as owner of Ne progeny, or my employees with wages Y thehaolecmpematim,
will do Ne work,ad Jcam eture, is not intended of offered forsole(Sec. 1061. BeinCes
ad Professions Code: The Contractor's License taw does on, apply to an avner m
propmy who Wilds or improves thacon, sod who does such work himself da, through
his own employees. provided wt such improvements Are nee inuMd a offered rot
Me. If, however, the Wilding or Monvemem is sold within ore yee.f completion, the
owner -Wilder will heave tW Week. of proving that he did rat Wild or improve for pus -I
pow of me.).
❑ I, as ower Ne progeny, m reclusively contracting wine licenced conmutma to
cesrrud Ne jam (Sce.1Oats, Business and live, feAAiom Cole:) The C.ntrex, turce LL
reae law not agply m an net of proper, who Wilds m improves thereon. and
whoconOncl tomb pmjeca withis conmactm(0 licensed Waumt W the Centnctafs
Llan a Ice
❑I m Sec. . B k PCfathistenon
Cr I Date 3-27-0•
WORKER'S COMPENSATION DECLARATION
1 herby A -Z under pentlty of perjury one of the following declaretiom:
I Neve end will Iminuin aCenidca¢ of Come., to sel6insum for Worker's Compcn-
tiprr, n provided for by Section 3]00 of the Labor Code. for fie performance of the
work fm which Nis permit is issuon,
❑ 1 have and will matown Wohcrs Cmpe ee Imunema. a repaired by Section
3100.(dee IoW, Cade. for the pertonname niche work for which this permit is issued.
My Workers Compcwtion Insutame carnia and Policy numbs m:
Carie,: Policy No.:
CERTIFICATE OF EXEMPrION FROM WORKERS'
COMPENSATION INSURANCE
(Thissectinn ed not WcomgletM if Ne permit is faone hundred dnllmm($10))
or less)
]Canty {U�t{111aIt lie performanx.fNe work for which this permit is issued, l shall
no Cmplo y manmr eco a to become aubjecm to J Woke Cmgen-
aetion La o cell m Dau
Applica t
NOTICE 10 .ICANT: If, mu making this Certificate of Exemption, you slmuld
become subject to the Workers Compensation provisions of lie tabor Code, you must
fonhwiN comply wide such provisions or this permit Nall be daemon revoked.
CONSTRUCTION LENDING AGENCY
Q Q IWffi
hereby arm that Nem mun
is aconsrmeJon lending agency teethe rcrtoce of
Z 2 Ne work for which this permh is issued (Sec. 3097. Civ. Cj
I cders Name
> I sedate Addraa
kiI Certify, Nd at 1 have reIbis application and AMC that dee above information is
CW z cosec,. l agree to Comply with III city ad county eminences AMI sone laws slating to
z building conduction, and hereby auiamice reprcsenretivn of this city to enter upon lie
U C above-mentioned prolixity for inspection purposes.
I's t.y 159e) agree to nave, indemnify and kap learreleve the City of Cupemien against
O U liebihu jdgmats, .am and cawaxawhichresyinan, wrymcmeegsirte, aid City
con taco(thegramingof Wspcmlit.
F APPI ANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NON.POINT
f..! Z :YULAnorvs. w
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future Wilding mcugam rnre or handle hanudous ma4rial
are defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(aft
❑Yes G�
Will AN, explicml or future Wilding cectewo use epuiprem or devices which
mil Naudoua ah contmimnts a defied by the Bay Acca Air Quality Menagemem
�npatrimR
' ❑Yes [�6'O
1 read Ne hasarduus maleriala reyuitenunu under Chap cr 6.95 M the Ca..
(min N & Safmy Code. . 25505, 25533 and 25536.1 undersand that if the
W' n ummly have a comm, that it is my responsibility m naify the necupmt
of awhich musIv, con pita to Murree of n CmmOeste of Occopmy.
CONTRACTOR INFORMATION:
CovS-,A� 014 W^/
(009 c.OS ,V/NOS Wfiy
LCX fF n* Cal %qo z-
(os'O 904P 75.0
Job Description
-resin r.riin.nnfu �1�0Z�
Sq. Ft. Floor Area 1=;06
IN
wAn
BUSINESS
YERMII'NU, ,/
LICENSE
REQUIRED
it s
!I MAR 2 7 2000
V
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0
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 Date
OFFICE
All roof coverings to be Class "B" or better
s