00040017BUILDING DIVISION PERMIT
a>to
Nz LICENSED CONTRACTOR'S DECLARATION
2 O y — 1 hereby affirm But 1 was licensed under provision of Chapter 9lcommeneing
OZ —J with Stenon 9000)ofDivt'sion Sof Business and PMmiom Code. andmyllanse is
FscCJ
6ceR,Q in fun force and <Rc qps
55 Lice wa Clan Lic.as
3
LL
y Daa Conuxmr ..
s- u. Oa ARCHIT'ECT'S DECLARATION If
2 1 undammad my Plans "I W used as public iscads
as
u a O Ucensd Profeaaional
peri OWNER -BUILDER DECLARATION
t z Q 1 bcmby af. Nat 1 am exempt fsom Ne Compactors License Lao, for the
❑ following ..neer. (Section 703 1.5. Business and Pmfea ion Cade: MY city a wunry
as tau 3 m which Requires a permit an construct, Wer, improve, demoliah, or repair any amxmn
prior a it issuace
n, also" "mines theipplicam for such permiva flea signedealemem
that he is licensed pursuant to the provisions of the Contractors License law (Chapter 9
(commencing with Section 7008 OI'Division 3 of the Business and Professinu Cade) or
Ws he is exempt therefrom and the basis for the alleged exemption Any violation of
Section 7031.5 by any applicant for a permit ubjects the applicant to a civil penalty, of
Out more Nan rive hundred dollars (5500).
O I, as owner of the, proper y, or my employees with wages as Neu sole compensation.
will do the work. and Ne structure is not intended or offered fee We (Ser. 70U, Business
and pmfensions Cock The Contractors License Taw does era apply to an owner of
property who builds or impmves thereon, and who does such work himself or through
his own employees, provided But such improvements are out intended Or offend for
tole. If, however, the Wilding Or improvement is sold within one Year of mmpleion. the
ser -Wilde will have Rte bollen ofpmving that he did era build or improve fa par.
pose of Rale.).
❑ 1, as owner of the Property, sm exclusively convecting with licensed canpacton to
construct Be project (Ser. 70m, Business and Professions CdR:) no Conmctm'u Li-
..
Lcame law does trot apply to ser owner of property who Wilds or impnayss tlrrton, and
who compacts for such pmjau with a commuctaw licensed portion, to da Contractors
License Law.
❑ I an exempt under Sm. . B At P C for this mown
water Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penWY of penury one of the following dedamtiau:
❑ I have and will maintain a Certificate of Conau
eno sel6m
inm for Workers Comp -m
noon, u provided for by Section 37W of the Labor Code. for the Prof. ce of the
oh for which this permit is issued.
L3 I have and will maintain Worker's Compensation lam., as mquind by Section
37110 of the UW, Code, for the performance of the work for which this permit is issued.
Mywaaktt%camperuatimn�Ixaf.nee <.rPer ane PaBcr:9 JErfF�scfi'a 46+
COMPENSATION INSURANCE
(This section mad nal becompleted ifthe permit is forome hundred dollen CHH)
or less.)
I certify that in the perfomteneeof thewak forwhich this permit is issued. ) shall
rot employ any peron in any manner as as in bocomc %abject to the waken' Contain -
union laws of California. Date
Applicant
NOTICE TO APPLICANT: 1f, after melting this Cer ifna of Exemption. you should
become, subject to the Workers Compensation Provisions Of the labor Cade. You must
forthwith comply with such provisions a this Permit shall No deemed revoked.
CONSTRUCTION LENDING AGENCY
Q I hereby affirm this there is a commission lending agency for the peRomunce of
z the work fa which this pcmtit is issued (Ser. 3097, Civ. C.)
I;w4 Camara Name
[� ii Lenders Addm%%
r� I certify that I have read this application and nap that On, above informbon is
6, carat. I agree to comply with all city ad county ordinances and Rule laws o ldng to
v O Wedding construction, and hereby mayearia representatives of this city to aur upon the
ebova-ma ntion<d pronely for inspection purposes.
k4 L.t
(We) agree to save, indemnify and kap humlas the City of Cupertino against
CJ liabilities, judgments, costs and tsperawas which may in any way game agdnat said City
} W in consequence of she grunting of Nis perm t.
[� d APPLICANT UNDF.RhTA' A 11.1. CORWIN WITH ALL NONPOINT
SOURCE REG 10
C/—S— 00
Si ppli an on Dau
HAZARDOUS MATERIALS DISCLOSURE
Will the anplicant or future Wilding acupan..tore or hands hazardous maledal
in defined by the Capetian Municiptl Code, CWpler 9.12, am the Haalth and Safety
Code, Section 25532107
\ ❑Yes Bg�_
Will she applicant at future Wilding Occupant use equipment or devices which
'mit hannfo , W commitments a, defind by the Bay Area AG Quality Management
is. ElQ�
Yea
I 1 have Health
At ashe h ode. Se tmledW requimmeno tomer Chapin r 95 of the Cali -
I forma Health At Safety Cade. Savom 25505 J] end 25570. I undersand Net if she
Wilding don res cuermigly atemnh s my reapmaibility amity the occupant
ogthc ny rust W nen to a ante a Cem cm, MOaupaney.
S GO
ownerosperaidirm'a .gent Dam
ERMIT NO.
CONTRACTOR INF/ORMATION: O b b T 0 o I �'
SANITARYNO. 1 APPLICATION SUBMrITr
g40" rc s. NIC CON RRL#
Com, �r�-rn.� ❑
IIULDING PERMIT INFO
253-0 &is
Job
b�'jDescription
Sq. Ft. Floor Area Valuation
daa. C'Z'
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 aggee to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of Applicant
OFFICE
All roof
Date
to be Class "B" or better