00030067 ARCCIIIIT[CTOF GINUEPF.REGSR'T)S1N•O\/
PERMR NJO.
BUILDING
nOPERMIT CONTRACTOR INFORMATION:
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BALDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION Job Description
Oo H? I hereby affirm,that I am licensed sada provisions of Chapter 9(commencing p
F=C.wi wid�5«tion)000)ofDivision3ortMBusixasaM im+Code.WmYliameis A y, /•,
z in full twee an e t. 1QJ� S�{.� ���•s Fa V V�
ti
OW u License a I_ Lic,N ,/ ^A,— /_A,y
O ARCHRE(TS Ds pas ALTO
1 udentuW my Dam sNil lighted u public records
'e Co ucansd professional �.9—_ D
OWNER-BUILDER DECLARATION KLN
1 hereby afl;ren that 1 em exempt from Ne Cormsctoh License Law,fm the '
E O following reason.(Section 7031.5,Buurcss W Proteuiom Coda My city or county
Swhich tcquirca a permit a conswet,that,improve,demolish.or npur my awetwe SqFt. FI Are ,.y Valuation
prior to its iommum,also im u res the applicant for such permit to File a signed summon . q
that he is licensed punu,to the provisions of the Contractors Liana Law(Cnapter9 rl a�
(commencing with Section 7(AW)of Division 3 ofthe Business W Profruioas Code)w Ap Nu bei
that he u exempt th arfrom ad Me basis for the alleged exemption.Any violation of Occupancy Y Type
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penthy of — O/o—
not
D"(�-0 s • a �.
pt nron Nan Eve hurdrd dollars(5500).
I.as ownernrthepropmy.mmyamDlnyaawithw.gasasthekmkaampematian. Required Inspections
will do Ne work,and the eauctun is M intrusted or offend for sok(Sec.7014,Buurau
and Nvfemom Cade:The Contractor a Liana law does not apply to an owner of
property who builds or imPmva nhe ch improvements who does mac t mk hied o r a tlwugh
his own oweverarnplayers,the moddd Mw etch entisoldw art not inaMd m offered for
ma.ILhowever,thebuildingunimprovement isatbwithinorcyetof ammpldor the
wmr-buildtt will Mw the buden ofprovin6 that he did not build or improve for pw-
pmseof ounc
I,u menet of the 704,aexclusively conmmting with Ikamd contemn t- �/
constructnstconstructrhe project(Sm.
Sa.704m 4.Busircu ad Profeuiom Code:l The Convecrore Li-
cense law docs not apply to an owner of progeny who builds or improves Marron,ad /
who contrmts fmmch pronatis with a eona.emr(a)r amed Mention mthe Cunaectors ^/
License law. C
❑lam cr'tun - .Bk PCfi Ili, O
A.m
ner —. pea 1 cc)
WORKER'S COMPENSATION DECLfRATION
1 hereby affirm under penalty a(parjury ma,of da following daluatiom:
I nave ad will nuimWn•CcniOcate of Comml m elf-insum for as provided for by Section 3700 of the Libor Code,for the perfomoama of the
work for which this permit is ismd.
El I have and will maintain Worker's Compensation Imurmce,as requirrd by Section
3700 of the Labor Code,for Ne performance of tee work for which this permit is ismd.
My Watkgl Insur rE CFF 'a and Polic r
Cafiv:�an Policy No.:
CERTIFICAPI'ION FROM OR
COMPENSATION INSURANCE
('Ibis action need not becomplered ifthe permit is Rome hulled dollen(SIM)
or las•.)
I comfy that in the perfom urm offhe work for whim anis permit is issued.)shill
not employ any person in my nnnKr m u to become subject to the Workers'Compere-
Moon laws of Glf6�m�ia.Da
ANOT antl�
NOTICE PLTCANI:1 after g rhte CeniOcnc of Exemp imn,you should
become m,*t to the Workers Compensation provision,of rhe Labor Cde,Yau Mgt
forthwith comply with such provisions ne this pcmtit am,be damaged revoked.
CONSTRUCTION LENDING AGENCY
0 I hereby alarm Om Mien is a commuction lending agency for Me,performance of
Z the work for which this permit is issued(Sec.3097,Co.C.)
L<wlars Name
[( 7 lenders Addnas
Wrz I certify Man 1 have red this eppliation and aate than the above infommien is
d correct.I agrae to comply with alt city and county ordinances and sane laws meting no
p Z Wildiri, onstmetion,and IMMY.mhosiu arInceenmives of this city to enazupon Ne
C.) 0 move.memioned property for inspection purposes.
Gla Eat (We)agree to a..iden eRy and kap harmless the City of Cupertino-Sunt
0 V limili,u.jdgmanu.emu ad eapemcs which may in my way am—agunu said City
�. B7 in consequence of the Bowing of this permit.
[� d APPLICANT UNDERSTANDS A No WILL COSIPLI'Wo11 ALI.NON-MIN'T
VSOURCB REGUlAI IAN' 14(oLD
signammofCan, aa. Data
RDOUS MAT 1 IS DISCLOSURE
Will Moa ant or fummbuildin .upmt StM or handle haMickue mgadal Re-roofs
as defined by the Colin,Municipal Code.Chapter 9.12.and the Ilmhh and Safety Type Of Roof
Code.Sectio 25532W)'! YP
❑Yes XNo
Will the applicant or future building occupant ase equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hwudous air conamirunu n dmrcd by Ma Bay Ana Ab Quality Management installed. If a roof is Installed without first obtaining an inspection
mki7 I agree to remove all new materials for inspection. Applicant
❑YesNo
IF (have rid the haaardaus materials rcquiremena oder Chapter 695 of the C.B- nn erstan and will comply with all non point source regulations.
fomite Hula B Safety Code.Sections 25505,M533 ad 255X.1 udaztual Mut if the
building dna ma torte haveuemnt,that it is my msponxibility anwify the rampant ` V
of the nyu've ch mor met prim ro asuwe if a Can fi�99m^fp�-Oauparcy.
i - Signa re of Applic• Date
Own orizd agent `Date
All roof coverings to be Class"B"or better
OFFICE