00040075BUILDING DIVISION PERMIT
20(,6p Sc:ocleJd �e
LICENSED CONTRACTOR'S DECLARATION
I hereby afiinn that 1 w liccued under Provisions of Chapter 9 (conuercing
with Section 70)(1) of Division 3 of the Business and Professions Cade, my Housnow
in full force said effect �s
License Class C LIC. Nso
Date Conbactm
ARCHTIECI'S DECLARATIO
I understand my plans Mall be used u public recuts
Licensed Rofeniosul
OWNER -BUILDER DECLARATION
I hatcby affinn m that 1 ae.mupt from the Conrrwme, License Law for the
following Baum. (Section 7031.5. Business and Prefessioo Code: Any city or ceanry
which relates a portion ho construct, altar. improve, demolish, or notion my avuctue
prior se its iuuwtt, aim requires the applicant your such permit to file a signedlstetemem
that he is licensed punumt In to provision, of the Connmtore License law (Chapter 9
(commencing with Secret 7") of Division 3 ofthe Buuen and Profusions Code) or
that he is earmpt therefrom and the huis for the alleged exemption. Any violation of
Section 70315 by any applicant fora permit aubje s the applicant to a civil Mistily of
nm more Nu five hundred dollen ($500), r
❑ I,mawoer a(Ne propeny,ormy employ« with waguu meirwl<compe...a.,
willdothe work, and mhertromme is not intended eeofferedfor We(S«. 7W, Business
and Profession Codc: The Contrac ti's License law does nm apply to m Omer of
propcny who build, or imprmou thereon, sol who does such week himself or, through
his own employees, Provided thas each impmvemenu art mo intendkd or offered fee
We . If, however the building or impwvcment I. sold within ane yuraf complcuan, it.
owner -builder will have the When of proving that he did not build or improve (or pun
pese of sale.).
I, as swear of the properly. sen exclusively coauwtin, woh licenses.smarten to
nseLat the project (See"Iy ,not 70,14, Business oft ma Rofeuiom or it'Ibe Conuecmrs Li -
muse whocLaw does rat apply e ts ownar of Propmy rout builds m um to
Nortons and
who Law. for such Maj«u with aconascmdy licenced punuwl m Ne Canhwtm't
Littre law.
❑tum exempt under Sm. ,B RPCfor this reason
ower Dem
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penury of perjury are of me following declinations:
1 have and will maintain a Cevificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for Ne performance of the
work for which this permit is loud.
❑ 1 have and will maintain Workers Compensation Insurance. n requirr4 by Section
3700of the labor Cade, fu the podormue of the week for
�which thin Permit its issued.
My Workef i Ingupgp. carrierpolicy No.and Y n^+ ca 7 L
Carrier: //'11
CERTIFICATE OF N FROM WORKERS'
COMPENSATION ININSURANCE
(This xcunn need not M completed i f are pend t is for ooe hundM dol w (3100)
or Icu.)
1 certify sac c the mffumarce ofthesouk for subject
this thenen is issued, I mall
not employ any person in my manner m n to become aubj«no the Warton' Compcn-
ppli Laws of Cui(rmie. Dem
Applicant
NOTICE TO APPLICANT: IL afar ranking this visiom of of Labor io d you should
heco.I a e..P m the Wohcro Cont or this pmvixitol of the Labor Cole, you ..it
(onhwiN comply with such provision or this permit shell be themed mokol.
CONSTRUCTION LENDING AGENCY
1 hereby ff.. shot Nem is a mmnumcm lending e,am, forth, ismi stnce of
the work for which this permit is issued (Sec. 3(97, Civ. C.)
Under. Address
I certify that 1 have read this application and nam that the above information is
erect. I agree to comply with all city and county ordinances sad stmt laws relating to
building construction, and hereby amhorie reprucnative of this city to enter upon the
abovamunrowned properly fee inspection Fortunes.
(We) agree to some, indenmify, and keep hmnleu the City of Cupertino option
liabilities, judgment, cow and expenses which may in any wry nectar, ,gums said City
in consequence of the graming of this permit.
APPLICANTUNDER. L DS AND WILL COMPLY WITH ALI, NON -POINT
SOUI�MI[ ATION
.V//
14
SigmmieofA Imanrr Dam
HAZARDOUS MATF,RIALS DISCLOSURE
Will to applicant or future Wilding occupant store or handle hazudess materia
an, defined by the Cupertino Municipal Cole, Chapter 9. 12. and the He" and Safely
Code, See ..25532!,)4
❑ Yes
Will the applicant or future building occupant use equipment or devices which
emit h eselous air commonenu�yjves donned by the Bay Ace Air QQualityme
Moms em
Di,nict7 /
❑ Yu
1 have reed the harardous materials requirements under Chapter 6,95 of the Cal -
forms Hee orS fcty Code. S«u s 255(15, 23533 and 25336. I understood met if de
building nes.0 I halt., Lthatanmyroponobilisymndi the o«uput
of she rtyu' n me primo, am.. ofeCenifice up
Ow mottru ol ge ' aO
PL `r r e`r'rh 1 //0 1 NIC
YY►Afz[44 C4 931933. ❑
4g3j s�y_s' X33
Job Description
ti /i—vo
6145 thncy�e
FL Floor Area
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
understands and will comply with all non point source regulations.
Signature of Applicant
All roof
OFFICE
Date
to be Class `B" or better