00050018BUILDING DIVISION PERMIT l,V1VIKAC iVK'"11VrVK1V1AlYVIV:- VO���� u
TING ADDRESS:
SANfrARY NO. APPLICATION SUBMITTAI
NIC CON ROLX
(p ❑
HULDING PERMIT INFO
IfliCl'niNGINIiER n tiles/C_!1 � `�
LICENSED CONTRACTOR'S DECLARATION
I hereby athrm Net 1 am liccnud under pmvisiom of Chaps, 9 (commencing
with Section 7(XXE ofDivlamrs 3 of etre Busineasand Rnfeniom Code; and my license is
in till force a.pe
jeme elan l-• T Lie,
Das - --Cm
ARCNDECTS DECLDEci-
AI A
I undersand my plans shall IN used as public nc«ds
Licensed professional
OWNER-HUB.DER DECLARATION
1 hereby aKrm that I am exempt from IN Contrmto's License Law for Ne
following Ragan. (Section 103 L5. Business aha Poefcafims Code: Any city or musty
which requirts a permit to c«rsuam, alar, improve, Aemthish, «repair any swcmR
prior m its i.tsuence, also requirts the applicant for inch permit to file a aigrsd atsumem
that be is li«sud pursuanuo the provisions of the Contractors License Law (Chapter 9
• (commencing with Section ]000) of Division 3 of the Business and Professions Code) On
shat he is cumpt therefrom and the basis for the alleged Gumption. Any violation of
Section 1031.5 by any app&ant for a pcmdt subjects the applicant e is civil penalty of
nm mors than live hundred dollars ($50(1).
rl L as owner of the property. or my employees with wager as theirule compensative,
will do tha work, end the amrcwrc is riot inrended«oRcrtd for We(Sec.1Ot4. Business
and profession, Coda: The Counter., License Law docs nm apply m owner
m a
property who builds or improvesthaem, and who dm. sum wait himself m though
his own employees, provided that such improvements ars not insnded in offered for
We. If. however, dee building Or improvement is sold within one yearof completion, the
m-Wildtt will have dee Written a proving that he did not build or improve for par-
poseof
otra
I• u owmf of the pmyeny, ant euros, my connecting with ) The Cemamws m
consumer Ne es am (Sec. 10 n Business rope professions Code:i The Contractors net
cense law dmf not apply m res owner of property wha builds or improves thereon, and
whofor such project with aconureer(rel licensed pursuemrothe Conuacmrs
Licensemn,"w. law.
�fdn caempt cr Sm. .BBPCf«Nis lieges
Owners
WORKER'S COM %NSATI NDECLARATION
1 hereby affirm send« pcnNty of �rjury oro of dee fallowing dcclvation,:
1 have atm will.,.Wn s Cenificm of Continuo mif insum for W«keesCompen-
otion. as provided for by Section 3100 of Ne tabor Code, for the perfomanec of the
work for which Nit permit is issued.
❑ 1 have and will maintain Weftes Compensation Estimates. as required by Section
3100uf the labor Code, for the pcdfmnnantt of dee work for which Nu permit is iumd.
My W«kces Compensation houranee carrier and Policy number are:
Curler: Pahcy N.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action suedrot Wcompleted ifthe pmu t is foroneh"Nol dolIars(3100)
or lus.)
I certify dm in the performame of the Omsk for which his permit it issuuL I shell
not employ my permit in my manmr so as to became subject to the, WorkesCreamam-
.tien Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, afar making Ni. Certificate of Exemption, you should
become sun*, to the Wodmre Compensation provisions M the Labor Code, you must
forthwith comply wish such provisions or this p<mrit shall be decried revoked,
CONSTRUCTION LENDING AGENCY
1 hereby affirm that shoe is a cmnatrocuon lending agency f« the pertnmance of
the work for which Nis permit is issued (Sec. 3091, Civ Q
Lenders Name
lenders Address
I unify that 1 have Rad Nis ti hcatim and use that IN above information is
comet I agree to comply with all city asset county ordiounces W aur laws rtlating m
building con,uuctim. and hereby authorize re,wenwiver of mus city to mss, upon the
above-mentioned property for inspection porpoises.
(We) elide to save, indemnify and keep handlers she City of Cupertino against
liabilities• judgments, cost and upenua which may in my way secure against said City
in
n.R9meme Of the granting of this permit.
APPI.ICAN'I' ON DERSTANDS AND W IIA, eC.ONPLI' W I ell ALI. NON.POIN'r
SGURCE:a �LADONS:
Sigmm c cf Applican /Comrerar Des
HAZARDOUS IXATERIAII DISCLOSURE
Will she applicant or mturt Wilding occupant core or handle hazardous material
as defined by the Cupertino Municipal Code. Chapler 9.12, and the Health and Safety
Cade, Section 2553241? -
C] Yet
Will she applicant or future Wilding occupant use equipment of devices which
mit haurdous air emeanrioams a defined by the Bay Arca AG Quality Management
elri?
co'.
I have tad dee hazardous materiala rcgmiremenu uMer Chapter 695 of IN Cali -
forms Health R Sat Code. Samo ss 255106. 25333 and 2553x. I undmund that if IN
buihWgdm. tcumntI heveet ant dw it is my respon,ibilay to really she«cupnt
Of the rest u whim tau b pat« o nuance o��nificate of Occup cy.
Owncradeu onzedagem Dese
Job Description
Valuation
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
under cads an will comply with all non point source regulations.
5--3- O�
Signature of Applicant Date
OFFICE
All roof coverings to be Class "B" or better