04100035BUILDING DIVISION' PERMIT
ARCHITECDENGINEER:
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professin is Code, and my license is
in full force and effcm DEMO (1ST FL. )
License Class Lie. M
Dam Counselor
ARCHITECTS DECLARATION
1 understand my plans shall W used m public records
OWNER -BUILDER DECLARATION
I hereby offtrm that 1 am exempt bre the Contractor's License Law for the
following mason. (Section 703 1.5, Business and Professions Code: Any city or county
which myuiee a Permit to conswcL alter. improve, demulish. or repair say sanctum
prior to its issuance. also cauims the applicant for such permit in file a signed s broom
that he is licensed pursuant to the provisions of the Contractor's Limn a law (Clam er9
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
that he is exempt therefrom and the but, for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars ($510).
❑ I. se, owner of the property. m my employees with wages as their role compensation,
will do Ne work, and the structure is rot intended or offered battle (Sec. 7094, Business
and Professions Code: The Contractors License law dos net apply to an owner of
property who bu Ilds or improves thereon, and who does such work himself or through his
awn employees. provided that such imparamenmare natinended oro@ed Russia. IL
however. the building or improvement is said within one year of completion. doe owner
builder will have de Warden of moving that he did not build or Improve for purpose of
4 1, as owner of We property, am exclusively convecting with licensed contractors to
crammer die project (Sec. 7W, Business and Professions Code) The Conmetor's Li.
came Law does not apply to an owner of property who builds or improves Merton. and
whocanuacmfora chpmjecuwiNaconvacortUlimnwdpumuammN Convacmes
License Lew.
❑ lame ntlerf5e/yf�-- 0kPfo thi/m on
Dave O f/
Y.BR$ GQh]Pdq�ATION DECLAR/�oN
1k Ihereby elBrount rpenelty al"derjury ane of the 1howing declensions:
rf have and will maintain a CcNRcae of Consent in sell -imam fm Worker's Compcm
tion, as provided for by Section 3700 of Jus Labor Code, for the performance of the
work for which this permit is issued.
Worker's Compensation Insurance, as required by Section
the performance of the work for which this permit is issued.
Insumrce carrier and Policy number sec:
_.._ Policy No.: _
not W completed iflhe permit is faranc hundred dells SIN)
1 certify that in the performance of the work for which this permit U issued,) shall not
employ any person in any manner so as an become subject to the Workers' Compensidon
Laws of California. Data
Applicant
NOTICE TO APPLICANT: IL star making this Certificate of Exemption, you should
become subject to the Worker's Compensation previsions of the labor Code, you must
forthwith comply with such provisions or this permit shall be deemed evoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a constriction lending agency for the performance of
the work for which this permit is issued (See 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have mad this application and stem that the above information is
correct. I ogee to comply with all city and cmniy on inanca and state laws relating e
Wilding conswaion, and hereby suthodre mpmsentatives of this city in enter upon the
above-montioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
COMPLY WITH ALL ION -POINT I Issued by: y
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m future building oceupamnore or handle hnudaus mamrial
as derined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Cole, Section 25532(a)7
kt❑ Yes
Will the applicant or future building occupant use equipment or devices which
humadnus air concealment as defined by the Bay Area Air Quality Management
iwil /
7Yes "14Nu
Jou not cuu77��nal //have a board, that it is my
.quimmcpLaJv IV
must b9 mdt our a anno
Re -roofs
Type of Roof
reanwil
PERMIT ISSUE DATE
SANITARY N0. CONTROL NO.
BUILDING PERMITINFO
SLOG ELECT PLUMB
t� 0
Job Description
O15�
Inspections
Date( `,/�
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.
Signature of Applicant
Date
All roof coverings to be Class "B" or better