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BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0003 O 1 r] L/
BUILDING ADDRESS:
ARCHITECT/ENGINEER
0/14
LICENSED CONTRACTOR'S DECLARATION
I hereby of rso that 1 am licensed maker provisions of Chapter 9 (commencing
with Section ]OW).Mivition 3 of the Businca,aed Piofessiorn Code. sM my license is
in full force and eBe '13q?"70
I Cl �Llc.g
Doc A—� O —� Canuwwr
I askfea-UX& LA V.
ARCHITECT'S DECLARATION
1 understand! my plans shall be used u public record,
Licensed PwfessimW
OWNER -BUILDER DECLARATION
I hereby affmt that 1 am exempt from the Commences License Law for the
Following lawn. (Semon 7031.5, Burns. ane Isofusiom Cade: Any city or weary
which 2quims a pump to comuuct, elm. improve, demolish, m repair my stramone
priorro as iswanw. also na9uims the Winans, favuch person to file • signal nacmem
Wt M is licensed pursuanuo the provisions of the Contrac m's Licame law (Chapter 9
(commencing with Section]000) of Division 3 of the Business and Ix ion. Cor or
that M is exempt thasfmm ane she basis for Me alleged exemption. Any violuion of
Section ]031.5 by any applicant for a permit subjects the applicant to a civil penalty of
t name Nan five hundred &It=(3500).
L] I, as owm,oftM propeny,amy employ«s with wsgmutheir role compenauial.
will do The work, and the structure is not Intended a offered for We (Sec. 7014, Business
"Profcwimru Cod[: The Convxwri License law does not apply w an owner d
proper who builds or improves thereon, and who acus such week himself Or through
his On employees, provided thea such improvements are not intended or offered for
We. IL hovere, she building or improvement is sold within ore yearofwsWladon, the
owner -builder will have the burden of proving that he did not build or improve for pur-
poseof We).
1, as owner of he proper• eon exclusively contracting with licensed contractors to
construct the pwjeot (Sec. ]OCC. Emmons and Professions Cede:) The Comncwes Li -
come law does rot apply to an owner of property who builds or impruvn thereon, and
who comrwts for such pmiecu wish a contrsaoge) licensed pursuant To the Contrecwd
IJcenw law.
❑ 1 ern exempt under Sm. . B & P C for this reason
Owner
Data
r WORIUSR.S COMPENSATION DECLARATION
1 hereby affirm under proudly ally of perjury oof the following declarations:
hove ane willnorby ateeihma of me Labor Codiuurthe dhersCempen-
work f r provided for mi Section 3]00 of the tabor Codr, for the pctfommnce of the
soak for which this permit i, issued.
I have and will maintain Worker's Camnsun
penwtion Ience, u required by Section
J] of she loner Cade. for the perfomentt of the wakfor which Nis permit is iecued.
My WerkeIns once cortin rod policy
Carie: Policy No.:
ons RTI FATE O ION FlCOM wG S'
COMPENSATION INSURANCE
This section needna becomplemd ifrhr Knout is forone hurdredl dollen (SIM)
or Icor.)
I anify That in the performance of she work for which this permit is issued, I shall
trot employ soy parson in any noon,, w u w bewme.eubjxt w tM Worsen' Compcn-
Wion laws of Califomia. Data
Applicant
NOTICE TO APPLICANT: If, afar making this CaniBcit. of Exemption, you should
hxnrrc subject to be Workers Compensation pmvision.s of the labor Code, you must
forthwith comply with such provisions a This permit shall be dressed evoked.
CONSTRUCTION LENDING AGENCY
Q Q I hereby effrtn that there is•wa,mcuon lending eg[ncy for the larfin sof
[, r4 the work for which Nie o tit is issued (Sec. 3097. Co. C.)
Lanese, Name
(� '7 land<Is Addis
LC71 anify Nat 1 have read bis application and male Net the above information is
IY 0cones. I stratato comply wish dl city ane county adwd ara
ncea ane laws saluting to
z building construction. and hereby aahaice repre2natives of this city to enter upon the
V Q abovem[ntioned mop<rty for impectimn purymscs.
fL E., (We) agree to rove, indemnify and keep hamdeas the City of Cupertino against
O V liabilities indgmenu, costs and expenses which may in any way accrue again, said City
} W inconsequence of The grunting of this permit.
E.
a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI. NON -POINT
SO CEREGUTA
�/vll� D3J�b-a
gi rtol Applic VCT— Data
HA mfar. MATERIALS DISCLOSURE
Will Ne a C.Tant or future building a. Chapt,nm or handle hazardous materia
m defined blithe Cupertino Muacipa Cale, Chapter 9.12, and 1M Health aha Safety
CodaYrs V5532(0?0 SC
Vas fitf)k,. ,
Will The applicant nr future building Occupant use equipment or devices which
mit haurdous air conumimnu u defined by d2 Bay Area AU Qtwlity Mamgemem
enia, `I
❑Yes gTNo
1 have read me hawdouuTuss material notiuimments under Chapter 695 of the Cal,
fir Health & S Code. Seen 2IM 2553) aha 255X.1 understand Nal if the
In doer nor havea anam, t 'nmy re"noibiiq w notify the occupant
of ,uaae of a Certificate MOccupvay,
eu seal gent Daa
LCjS-t ,re. L -M ci nal
c� S i an, I�G
1117 Kelca v�
�� J0Q'e% 951
4-09-q0-7-7117
NIC
I BUILDING PERMIT INFO - -
Job Description
B U.i I d- res z L'_41 PO-h'O -e. C,t orv�.
—rn4Z
Re -roofs
Type of Roof
3'/mss^
/v
O
3a�2_/b
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
OFFICE
All roof
Date
to be Class 'B" or better