00030182BUILDING DIVISION PERMIT
LICENSED CONTRACTOR'S DECLARATION
I hemby aRnn that 1 un licenced under provisions of Clupv 9 (mnanrnciny
with Section ]000)ofDivisim 3 of Ne Business and Professions Code. and my liamse is
in full force and effect.
Liana Class Li.. N
Date Co...,
ARCHITECTS DECLARATION
I understoodmy plus, shall to used u Public rteords
Licuued Rofeviaml
OW NER-BUILDER DECLARATION
1 hereby effrtn Chet I ern exempt from the Contractors License Law for the
following reason. (Section 7031.5. Business and Professions Coale: Any city account'
which reclaims a Permit in common, alter, improve, dem iliale, or repair any stmawe
primmis,i,swna,alsoma,iimuhe it licam forsuch permit m file it,,nndnetament
that he is I'clomed purswm to the provisions of the Convectors IJmmta Law (Clospanr9
INN he is esc with Sema l road of Division 3 aftha BUNmas real Rt. A., mCadet of
Sellae is 31.5 b therefrom and the burs for 0rc als than palmation. a civil
violation of
Section , thine by any d&It for a permit subjects the applicant to a civil Rmlty of
t mase Nen f ft incident propsdollen y employees
I,a,Owner of thepe Penn inmywithwas" atheir roll cam, Dust..
will professions
work, ands: ewcwm is trot encied!Livens or offenexiLaw
do for o apply ]066, Bmima
tad property
who
Code: The ovthereContractors Liana law nous no apply s an othro of
his O nY wlro build, or improves Nolan, and who nos, such sena himself or through
his own sow to m, builds nd thu such imptmenldw x trot intandnd a offered for
cwwcr.mlda,riulnabuildingmimprovement ithalhwithinowe ildlor vale fon. r par -
pow,
pow, We.) will M.v the bother of proving that k alk net WiW m improve for pm-
pou of acus.),
1, as owner of the PmRny am e,clusively contre<tin8 with licensed convmcmn to
mnswae1e"no""' (Sec. ➢144, Business and Rofeuions Cade:) The Convector's Il
¢n does nm apply m an owner of property wW Wilda or impnuvcs thereon, ren
wW trmufor such pmjmu with a contacmds) licensed psenuanl m the contractors
u Lew. r//
la nddnder5a. � .B&PC for thisewm
I hereby W under penalty of perjury om of the following declumiom:
,r]Iheve end will inulnaCenificataor Camenitoself-insurtforwakers ComWn.
/nation, m Rov' for by Section 3100 of the Labor Code. for the perlomance of the
work for which this pcmtit is ismcd.
I have and will maintain Workers Compensation hoommce, as repuird by Saner
3100 of the lather Cade, for the perfanmme of the wok for which this Permit is raved.
My Workers Compensation insurance oder and Policy number are:
Carrie,. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sation need nor W completed tithe permit is forome hundred dellen, ($I00)
Or Tess.)
Icenify that in the parftumanc, of the work for which this permit is.•• ad.I shall
ret employ any Rnan in any number an as to become subjem to the Wort Compere
saber laws of California. Data
A,hss a
NOTICE TO APPLICANT: If, after making this Cemilicam of Exemption, you should
hecurne subject to Ne Workrrs Compensation pmvnicm of the Lubm Cede, you amt
fonhwilh comply with such provisions or this permit shall be dectmd mvokcd.
CONSTRUCTION LENDING AGENCY
I homebY Mrm that them is a co boorstion lending agency N, the performance of
Ne work for which this morm is issued (Sec. 3091, Ci¢ Q
Lenders Name
Leader'; Addrt,s
1 cenify that 1 hive read this ii,bratirm and norm that the above infermatiob it
correct. I &gree to comply with all city send county' Ordinances tad auto laws misting to
building combination. and hcmby authorise tc maunds Ives of this city to enter upon the
abo,oremionW property fur impation pure e,
(We) epee to ave, indemnify and kap hamdeas the City of Cupertino agaimt
liabllme ,judgmenu, ensu and ,.,,pores which may in any way acme against and City
in consequence of Ne granum, of this Rrmit.
APPI ICd T UNDIiNSTANDS AM) W 11.1. COMPLY W I'fH ALL NONJOINT
p RDOUS MATERIALS DISCLOSURE
Will thea 111=forum Wilding accam, itoreor handle haesrdous material
ad by the Cor ire. Munici,el Code, Chapter 9.12, end the Health end Safety
❑Yes No
Will o e applicant or future Wilding occupant use equipenent or devices which
vasdous air cri.imenta rs defined by the Bey Ams Au Qality Management
❑Yea ❑No
I lave rod the h rmadoue material, onpitememn uMer Chapter 6.95 of the Cali -
bum a Health & Safety Code. Sections 255(15,15533 and 25534. I understand thal if the
AuildinoEmma cunendv beer,. a mnnm. that it is in, msoomibiliry ten nobly me wome nt
CONTRACTOR INFORMATION: I U
Ft.
Re -roofs
Type of Roof
Job Description
rntcmu No.
30(8"
APPLICATION SUBMITTAL
CONTROLa
LUNG PERMIT INFO
MAR 2 9 2000
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. Ap I' ant
understands and will pl with all non point sourc regulations.
l
S ihst&reof A Ir Dat
All roof coverings to be Class "B" or bet/r
OFFICE '