00030172BUILDING DIVISION
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm dw 1 am licensed under Provisions of Cooper 9 (rommenring
I-Ct j withSxtion7000)of D,v' Jof the Busi,au ad i myli«ueis
in full force cRat.
K < Licene Lic. M 'll
itDe¢LL N' Conuu
t LL O _ - RCIInTZ17S DEC
y a � 1 unaen mY Piens shall be tied u pubiic,w«ds ,
n. a Licensed Professional - -
OWNER -BUILDER DECLARATION
C z a I hereby affirm that I am exemp, from Ne Convectors License Law for the
O following recon. (Section 103 L5, Busixsg and Proreuioa Calle: Any city or county -
which requires. Permit to coeurs, alte, improve, detreclah„or repair any atmcturc
pnm
to its issuance, also requires she applicant for each Permit to file asignd alatcmem,
shat he is licensed pueaant to the pmviaiom of its, Contruwrs License Isco (Chapter 9
(Warranting with Section 1000) of Division 3 afth Businus ane Pmfeuiou Code)or
that he is eaempt to nefmm cod the basis for the alleged cumption. Any violation of
Section 7031.5 by any applicant fm a parmh &objects the applicant to a civil penalty of
nWo mme Nan five hundred dollars (3300),
I, u ownm of the progeny, m mY emPloycee wish wage u than cols cotnpswtiao,
and dome walk
ns ands: he C.re;e unintended o Law dos am appaJOas, Bud, a
and property
who
Cade: the Conahereo License ism dao nw appy to lf owner N
property who Wilds or improves; thereon, apr who a e c such Intk himself ti Nrough
his own employerse ptnaor it such ;vent is mid w are nos yaruld «.flame for
tile.ILhowere will
buildinguiesof Moving
ismidwithinnneyear intomkafor the
pose id Rdx will Haut th #Nen or ptaving Nat ba did nm bulla or ittspmve for pur-
[3 1 of sale.).
I, u, die of the property, un meresively conaacdng who Themed rma nee, m
Imm La the project (5x.10/,, ses, of and sy who oa Code:) Ten Canaecsors nd
came law dos rot apply to an owner o(pmperty who Wid! par imptovo Corson, and
won.contracts.f« such pmjecu with a contndor(s) Ikenad pursuant w the Contractors
Littnre law. , '
❑ I unexseeptstleer, Sec. ,B&PCf.rtoonawn
OwnerData
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under peulry of perjury one of she following bu, ensfcas:
j Ihave andwill mamtaraaCwficea ofC.,b,e,If-in&omfm Vrek .Ccm,m-
cation, uprovided Rely Section 3100 of the fabm Code, for she perforrurlce of she
work f« which this recruit is Issued.
1 have and will maintain Workers Compensation Insurance, as n,ui ed by Section
3100.( r
MY W eC.WcPo.Rdaeg,!fRT^-sPic the wisfermt limited,
f�which
IgTAa .A.
Job Description
000W) -7Z
&N0ON T Y APPLICATION SUBMITTAL DATE
5 3.2 '-ao
NIC '' CONTROL#
El
n Tnwr., EERMrryINro
A)t S F10 L
Sq: Ft. Floorea
GO3'Akiilr/1!/��
uaC
oY 3 5 LT
Incy.Type
-
IThig ylllu
«laq
'i1 tRafwilfohundrea
I «rti( t, Nrform f or tothispemtitisisud,lshell
not employ any Person in any menet so as to bccmne.wbject to the Workers' Ccrisxn--•'
J
cation lswg of calif.mia. Del•
-
Applicant
NOTICE TO APPLICANT: If, after making Nie Certificeu of Exemption, you should
-'
become subject to the Wrinkles Compensation Provisions of the Labs Code, you must
forthwith comply with such provisions or this permf ,"ll be darned mokd.
,
' CONSTRUCTION LENDING AGENCY
0 0
�rm that thereisaconatmctiov lending agency torso perfomunce of
In worU n Ifatr awlihich this permit k issued (Sec. 3097, Civ. C.)
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Uri None
�
t<ndcrs Address
Lri Q1
certify Ih,1 he. read uses application ad awe used mass ove off.fion ;s
S�LLII
Hat. I agrte to comply with all city and county ardiunEes and suite laws relating to
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building concoction, and hereby authmiu reprcsentstives of this city to enter upon the
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abovememiond property for inspection Purposes
(We) agrx m sews, indemnify kap I City
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soul unless the of Cupertino against
oabilitiesjodgments toga ad expeucs which tray in any way acme against said City
IP•, I:ii
in conu9uencs Ne gnndngof Nislzmlit
E+ A.
APPLICANOI ERSTANDS AND WILI.jjj!!l)MPLY WITH ALT. N-POIN'T
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SDURCP U ATI � / / ���
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—'- a
$15naarc old he Com
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HAZARDOUS CLOSURE •
4 t� 1 y
.rfar.MATERIALSu,ainv
W!bythell fMun opal Codsxupantnonor handle nuudaanmaanal.
Re -roofs - -
u dsfiad Cupertino
the Cupertino MuNcipal Code, Chapter 9.12, and the HeaIN and Safety
- -
Cd io s3xe
Type of Roof.
❑Yes �o I.
CYes
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..
MH ibe mphcan,.1 furore Wilding occupant sa equ;pmeni mdcvices which
All roofs shall be inspected prior to any roofing material being
emit baurdoss air wtwmirwa to defied by dis Bay Arca Air Quality Muugment
installed. If a roof is installed without first obtaining an inspection
al`roYtg [n
I agree to remove all new materials for inspection. Applicant . .
Ihvc orae Ne Asa.do,,, natewe rcquimnmuvodcr Chpter 6.95 of lh bli-
understands and will comply with all non point source regulations.
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Toni IN R Safety Code�Sav
25503,15533 and 25534. 1 understand than lithe
.
ban' , cs red currergis'hev na
t Nm it is jr, raponsibiliry hon fY do cupent
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Ivetiwnlawou
to time
signature of Applicant Date
r an:dav
�Diva
All roof coverings to be Class "B” or better
OFFICE