00040085CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Nat I . licensed under provisions of Chapter 9 (,.Oct.,
with Section ]000) of Division 3 of the Business and Profession, Cade, and my license is
in full form and effect.
License Class Lia N
Dale Costfacmr
ARCfffoK7S DECLARATION
I undenurd my plans NJI lax used as public rceoNs
Licersed PmfessimW
OWNER -BUR -DER DECLARATION
1 h,mby aflinn that 1 nm exempt from the Contractors License Law for the
following mecum. (Section 7031.5. Business and Professions Code: Any city or county
which requhes • permit an conamo , alter, improve. demolish, or rtpau any avenue
prior In its Issuance, also requires the applicant for such permit . file s si,ism statement
that he is licensed pursuant to da provisions of the Contraciots License law Chapter
(commencing with Section 1000) of Division 3 of the Business and Professions Cads) or
that he is exempt therefrom sed dte basis for the Jlegd exemption. My violation of
Session 7031.5 by any applicant for •parol' aubjects the applicant m a civil penalty Of
.in mom Nan five hundred dollen ($500).
0 h its owner of the property, or my employ., with wag. as their sole compensation,
will do the worr, and Neewcmre is nod inre sd or offered for We (Sri. 7044. Business
and profeasioas Code: The Contractor's License law does not apply to an owner of
property who Wilds or improves dsermn, and who dcans such week himself or through
his own employ.., provided thou such impto cmmts are n0 intended a offered for
ale. If, however, the Wilding or improvement is sold within one y.of mospldon, the
owrcrW i14r will have the burden of proving than he did not Wild or improve for per
pose of ouln).
❑ 1, as Owner of Be, property, am exclusively contracting with licewd conuac,or m
construct the project (Sec.1014, Business and Professions cod,:) The Conuecmrs Li.
cents law does rot apply to. oa. of property wed Wilds or improves thereon, and
who contracts for such projects with a conuactogs) licensed p usuent to the Contraclota
Limon law.
1 am exempt under Sec. . B & P C for this won
owner Dam
WORKER'S COMPENSATION DCCIARATION
I hereby affirm under pcnet, of perjmy one of Ne following declvatiom:
�] I have and will maintain a Certificate of Consent to self-imme for Workers Courser'
sation, ss provided for by Section 3700 of the labor Codc. for the performa.e of the
work for which this permit is issued.
❑ 1 have and will maintain Worries Compeoauon Immarce. as required by Section
371X1 of the Labor Code, for the pmfonname colic work for which this permit is issued.
My Wakces Compnmunno Insurance carrier and Policy number art:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPIENSATION INSURANCE
(This section need not bocmmpledeLifthe permil is fa o.hwdmddollen (SIM)
Or Ra.)
1 certify 0r' in the performance of the work for which this permit is issud.I shall
nd employ any person m any man e, so as to become xubjecno the Worker C.I.-
ration laws of California. Date
Applicant
NOTICE IO APPLICANT: If, after meting this Certikew of Exemption, you should
,mm. subjw. the Workers Compensation provisions of the Labor Code. you meat
forthwith comply with such provisions or this permit shall be deemed revokd.
CONSTRUCTION LENDING AGENCY
I hereby a fico that 0tert is a consroction lending agency for thc pMorhrume of
the work for which this permit is issud (Sec. 3097. Civ. C.)
landrrs Address
1 certify that 1 have recd Otis applicaliou and rate duet the above iMomution is
erect. I ogee to comply wide all tidy and coumy .o bances ud'late laws relating to
building corstrucdmn, amt hereby suthorize representatives of this city to enter upon the
sbove.r.n nned, property for ine,ection purposes.
(We) age. to ave, indemnify and keep harmless the City of C.,moo.,airs,
habihdes,jar,mcnta, costs and exprnas which may In any way'.rue age.. aid City
in
naquence of the granting of this permit.
APPIACANT UNDERSTANDS AND WI 11, COMPLY WITH AL1. NON -POINT
SOURCE Rf:GUTArIONS.
Signature of AppticanJConnacta Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding mcupam sure" or handle ha.Nous maeriJ
as defind by the Cupertino Municipal Crie. Chapter 9,12, and the Health and Safety
Code, Section 2553]4)^
❑Yes ON.
Will due applicant a future Wilding oemptim use egnip ram, or devices which
mit hazardous air contaminants as defined by Ne Bay Ma Au Quality Management
0Yes r7 NO
1 have read 0r' hmmMws materials requirement under Chapter 6.95 of the Cali.
forma Health & Safety Code. Swims 25505, 25533 and 25534.1 understand dust if ted
building dos mol euren0y have a ten mL, that it is my mponsibllily in Notify the occupant
of the requuemeas which must he trod prier to issuance of. Cmificae 4Omupsecy.
Owner or authorized agent Date
CONTRACTOR.INFORMATION: I 0 051 a
W
Job Description
4Fr� f0�
Sq. Ft. Floor Area
Issued prior to plan check completion
Contractor and/or Owner accept complete
responsibility for correcting additions,
omissions and revisions on
completed Blue Prints.
Permit good for (30) thirty days —
From -Y—
NM
�j 10J
- /3—
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
OFFICE
All roof
Date
to be Class `B" or better