00020177BUILDING DIVISION � PERMIT CONTRACTOR;INFORMATION:
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I LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nm I eo licensed under provisions of Chapter 9 (commmicing
wish Soclum 7"10fDiv'sion 3 of eBusinessanc Profess ons Cade, smi riserslice
in full face W eRcet.
U, meq _ - Li
ARHTIECYS DECLARATION
I underamnd my pW.. hadl be used as public rccods
Licensed Profneond
OWNER -BUILDER DECLARATION
1 hereby aRrm her 1 am exempt from the Committees License Lew for the
following maw. (Sution 7031.5, Busiass and professors Cade: Any city or county
wltich require a permit so compact, dem, improve, demolish, or repair any mossurre
Prior to its issuance, also requires the applicant fm such permit, file a signed statement
diet M is licensed pumant to the provisions of the Cort.,rs license Law (Clmpanm 9
(commencing with Section 7(XXE of Division 3 of Ne Business and Professions Code)or
Nm he is exempt therefrom and the basis fa the afegW exemption. A, violation of
Sand. 7031.5 by any applicant fm a pemm udpe s the applicant o a civil penalty of
not mom then five hundred dollen (SSo0).
❑ 1, As owner of do property, or my employees with wages as their In compensauor.
will tlo the work, and the structure is am intended or oRaW (or We (Sec. 7W. House.
and Profmtions Code: Tie Cmaremo mi License Law does oro, apply to an ams a
property who builds or improves thereon. and who does such work himself or through
his awn employes. provided tiro such improvemenu are nor intended as offered fa
pale. If, however, the building or improvement is sold within one yemofcompletion, the
more' -wilder will have the burden of proving Nu he did nm build or improve forpur-
"ofole.).
[:]1, re owner of the property, sm exeluuvely convecting with BCCmPd contractor to
onxtruc. rhe project (See 7040, Business and professions Code:) Tie Conbactm's Lt.
lemm Law does rot apply to an owner of propmy who builds am imamc.s thereon. and
who con "for such projects with a conbectm(O licensed punuam to the Convacuras
License law.
❑ lmnexcmptunder Sec. ,B&PCfordim' son
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under pend" of pe jury one of the following declare roar
1 have gnd will nuimaln a certificates, of C., to self -insure fns workers Compere
bre, as provided for by Section 3700 of the Labor Code. froth, perf sora ntt of she
VItar which this ainttiiis issued.
I have end will mammon Worker's Compensation work
for which
as his perm by Section
3IOOof the labor Code, for site pertomunee of sire wort for which Nis permit Is issued.
MY Wortu�CytgpcpygtfoQOudapce ca mend Policy by yte�O/O/u
Cenicc LL NN EE''NNaA1 ((JJ //VV m Policy Na.: YK J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or lase.) (This motion need nm hecompletW little, permit is faonchundedcallner ($100)
1 certify that in de pe formenttofthe work for which mi, permit is issued, I shall
not employ any person in any manner so u, become subject to Ne Wmi en' Comprm
anion Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Ce.ificam of Eacmpuon. you should
become subject 0 the Wmkds Compensation provisions of du labor Code, you must
forthwith comply with such providuns or this permit,hdl h deemed revoked.
CONSTRUCTION LENDING AGENCY
0 I hereby affirm dm Nem iso camtrocuon bding agency fom,W pmfrmtameof
z y the wank for which mice permit is issued (Sec. 3(097, Cr, C.)
F. Lenders Name
CG > tenders Address
fz7 E .1 certify Nm I have mad Nis aplu"Mion and suns Neo the above information is
Qo z correct. l Agree, comply with d1 city W county W homee, and nude laws rending to
Ud 0 building cowenu
nuctlov, anhereby Whicarme repostives of this city, mean, upon Ne
above -m nummod property for inspection purposes.
k. F (We) agree , save, indemnify and kap harmless the City of Cupertino against
0U liabilidojudgmentacoarowelperues which 'n any way wane agalnR aid City
>s W in consequence of Ne granting of this
permit.
F lZ)a- APPLICANT UNDERNTANDS AND ..I, " FLY WITH "con All
FfIINT
SOURCE RF.GULA 'S.
Signam2ul'ApplicanU ate
R a MATERIALS DISCLOSURE
Will NeAppRcam or furore budding oaupentsmre ahvdle haanam, mood, Re -roofs
as defined by the Cupertino Municipd Code. Chapter 9.12, and Ne HWth aid Safety
Code. Section 25532ud7 � Type of Roof
p Ves QNo
Will the applicant or future building occupant use equipment or devices which
coil harsrdam ab conumitunts as defined by Ne Bay Amu A'v Quality Management
Disvic0
' [IYes
1 have Head de herarduus maannids mquimmenss under Chapter 6.95 of the Cali-
famia Hnith & Safety Cade, Smtiom 25505, 25533 add 25534.1 indentured than if site
building does nm currently have a,enanr, Nasi it is my nstbility m amity the occupant
of de, rtyaimements which oust W Wosier,us faCemfcme or(kvw.e.v
PERMIT NO.
po�9,6 (
NIC
11
IaHRUI.ftl
Job Description
Alalzf,h #Pgf�r112
Ip/U�Pr rf �D qu/,�i1/yam
Sq. Ft. Floor
VI
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 'th all non point source regulations.
/� 00
Signature of Applicant Date
OFFICE
All roof coverings to be Class "B" or better