00040185BUILDING DIVISION PERMIT
LICENSED CONTRACTOR'S DECLARATION
p, O = p 1 hereby aarm tied 1 am licensed under provisions of Chapter 9 (commencing
<y'j wish Section ]Op0)ofio
Divisn 3 of she Business and Profession Cade, and my lit. is
sey V In full forceq�
Liunm Clea � IJc. x
3 LL f Dam comncmr
ARCHrfECI'S DECLARATION
5 v� 1 uMenual my plans shill be used as public resounds
CC 6f
i i o c Licc sed Pmfeuioml
n , OWNER-BUIL.DER DECIARATION
F Z r i hereby from that 1 am stamp from Ne C..'esc res u1mae Lew for sed
O following =me (Section ]031.5. Business and Praferriom Code: Any city or countyed
_
w6 3 m which requires a permit Is, construct, after, impwuc, demolish, ce repair my structure
prior to in Issuance, dao requires she a hIml foramh pared u file• dgswdaumment
that he is tinchund pusuam to" pwvidom of she Connector. I.icens Lew (Chaper 9
(commencing with Section ]0(sh Of Division 3 of Ne Business and Professlom Cade) or
that he is exempt therefrom and the basis for the dle,ed exemption. Any violation
Section ]OILS by any appOmm for a permit wbjsca the eppliunt so a civil pe a(
not mon Nen five hundred dollu+fS50o).
I,mowner of tied propeny,omy employees with wageushev aeric compere
will doodework, .nee: ln, is not branded moHercdforala(Sec.]044,wner
and mt, wbom Code: The over them.
ms's License raw doe not apply ot lf owns of
pmpeny wW builds or improves such improvements and wW does a work himself efeedthrough
for
his own employee, pmdAed r i such enis art eros intended a olltted for
owma,-however,thevbidingor en of mem issold within one ywof completion, the
we urnbider will have Nc burden of provint Net he did nos Wild or improve for pm-
pos of swp
❑ L Consumes owner of the Seeproperty.704 ' l ealusivnd connecting with :lame Ccotrast.I to
..-aNe erojccs (Sac.. an Business andprofessionswho ho Code:) The Comrae m. n
wens law does ren apply jo ts owner of propmy who Wlldt a impose thaton, and
who contracts for such pwlecu wish awmtrecmr(s) rwensd pursuammshe Com,acmr.
License law.
❑ 1 em exempt under Sec. . B & P C for this won
Owns Data
WORKER'S COMPENSATION DEMRATION
1 hereby effrm under penury of perjury one of the following deeluatiom:
) 1 have end will maintdn. CeniOeme of Comms m slf-insure for Workers Compen-
sion, as provided for by Section 3700 of she UWr Cods, fa tW performance of she
wIIIIIIIIIIIIv,.rk for which Nis permit is issued.
I have ane will maintain Workers Compenstim Imurmce, m seedbed by Section
]o0of the UWr Code, for the perleme x ofthe work for which this permit is issued.
My WorkelCompeemi. Inwrans carrier and Policy number me: _
COMPENSATION INSURANCE
(This section need ma be,cmnplare l ifthe permit Le foone Whetted! dollar SIM
or less.)
1 amity that in she performance of the work for which this Amus is inted.I shag
ret employ any .on in my manner s noun bacon¢ std ecmo the Wahen' Compen-
sation Iaws of Califomi.. Due
Applicant
NOTICE TO APPLICANT: If, at.. melding this ourdieem of Evempim, you should
become wbjec'to the Workers Compenimion provisions of she UW1 Cale, you man
foMwith comply with such pwvlaienn or this .it dull W deemed revoked.
CONSTRUCTION LENDING AGENCY
Q O I hereby dfrtm U t is i a w (SM. 30 lending agency for she perfomwce of
Z do wok ran which Nis permit is Tuned Isco.1119], Civ. C.)
Fed 4 Lenders Name
a' Lender's Address
I amity thin I have reed this application snd man that tis above information is
a e court. I agree m nd comply with dl city acounty Inc m es did sun laws Mimi" so
Z Wilding construction. and hereby audwrim mpresnutives of this city In enter upon the
U 0 above-mentioned pmpeny for inspection purynses.
(ae F (We) agree to save. Indemnify and kap harmless the City of Cupertino ageimt
t> liabilitie, jvdgmenu.cmu and, expenses which may in my way eame,gmot said City
y t
L emselocnee of Ustargronst, of this permit.
't•+ 0 o PPLICANT UNIIP:RS3'ANDS AND WII.I. COMPLY WITH ALL NON -Ml N'I'
U Z souuy!Irculn'nous.. A
. WillN.,hcod or future Wilding rce.,onsmem hmNe heemlous marcid
as defined by sur Cupertino Municipal Cade. Chaptt 9. 12. and Ow Health and Safety
Code, Satire 2553att ?
❑Yes ❑No
Will the applicant or future Wilding eceapann use equipment or devices which
cot hamdous air tmorchirunu es deEned by the Bay Asa Air chdlty M.ttatement
[I Yes E3 No
I lave nand the hamrdms ma .rids neytonemena under Clo ter 6.95 of sur Calm
Iu1N & Safety Cade. Seen. 25505, 25533 and 255:N.1 understand that if the
s dos sews cusscntiy have a seiner, that is is MY Msponsi uhry m notify the recount
nexutremenu
0--, �'Pi ; (�z
,4 3 7 4,, 4 A/c,
Sy. Ft. Floor Area
J APN Number ssT
'YJ/—�-�
Job Description
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 Date
OFFICE
All roof coverings to be Class "B" or better