04120055BUILDING DIVISION PERMIT -
NOVO CONSTRUCTION
NAME:
0a p LICENSED CONTRACTOR'S DECLARATION
I hereby sffirm that 1 am liceaed untie vmio s of Chapter 9 (commencing
.it do07 )arDivi4on3afftB Profcssioa C.de.andmylimmis
in full to arc 7y'loZZ TI --SHELL
q Z Licm Lin. Y
t=ku9 Con r
aRCHRF[TS [) ON
j8 1 unMnush
nd my plana all W used u pulse, rewNHs
3 LL � Liconad Par enter l
='D OWNER -BUILDER DECLARATION
N
1 I hereby an'mm Net 1 am1. exempt fore the Contractors Co License Law far the
i p O following mum.. (Section 703 constants.
Business and ver. donee Code: Any city at county
.1$ �a which rtquirca • Permit m aanswcL alter. Improve. tlemol W, or repair anY SIIYcnum
Prior in its issuance. 9laa anpu a die applicant for such permit to file a signed slaemmll
that he is licened pursuant to the provisions of the Contractor's Liceoe Law (Chapter 9
zC$ (commencing with Section 7n W) of Division 3 of the Business and Pro@scions Code)or
a
door M is evanpl therefrom and the basil for the alleged exemption. My violation of
Section 7031.3 by any applicant for a petit suhjecu the applicant s a Civil Penalty of
net mom than five hundred dollars ($5007.
❑ 1, u owns of that property, or my employes with "gas u their able compensation,
will da Profession,
work. and ds he Con a me, Lkera aromred rarssle (Sac. 70th, Budrcas
and property
who W Code: The Caterers rad who law doe ml apply lf an owner is
OwnOf
erlywho Wilds orireprowslh Improve who dosouchwodt oroffeorthmugh his
ownemployes,povided Improvement is
not IntendedmPlcfi dImsele.if.
bawewn the have
thWilding car Impowment u halt within one )ear of mmove for the ase or
er-
Wlider will hew the burden of paving Net he Old net Wild or improve for purpose of
talc.).
I, u owner of de pastry, gm taclusiwly em"ming with lieenad contrhasn m
2 ,met the Posner (Sec. 7044. Business and Pmfneslao Code:) The Ca raceh U-
conae Law does not apply s an owner of pmpeny, who Wilds or improves theme. and,
_ who contracts for such prejeeta with a eonoacter(.) licensed Pursuant lathe ContraceYa
License law. n
❑ tem .sere [(rade Sea �j .B hPCfm this recon
0 a".�
WORKER' COMPENSATIONO N
I hereby &Man under penalty of perjury am of lowing dmlentiorts:
1
have and will maintain aCenifncamof Cansenitoseff mumforWorkeYSCampen-
sation, as provided Ter by Section 3700 of the labor Code, Ter IN performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance. u required by Section
3700 bf the Latter Code. for the performance of the work for which this permit is issued.
My WC,
Compensation lmmance carrier and Policy number an: -
(Diet rmrian need nut be completed If the remain I. froom hundred dollars is 100)
or ISssJ
1 certify that in the performance of Ne work for which this petit is issued. I stall Out
employ any person in any reamer an as in become subjnet to the Workers` Compensation
La" of California. Data
Applicant
NOTICE TO APPLICANT. If. after making this CcnlRcam of Exemption, you should
become Subject to the Worker', Compensation provision, of the Labor Caere, you mus
Oforthwith comply with such provisions at this permit hall he deemed rooked.
Z "' CONSTRUCTION LENDING AGENCY
[n
4 (hereby affirm that Nave its Continual. im,fingagoney fm On, perform. of
C > the work sur which this Permit Is issued (Sec. 3097. Civ. C.) -
Wry Q Ureter Name
i7. z Lenders Address
V I cmlfy that 1 have mad this application aed sum Net the abova infatuation it
LL !+ totem I agree in comply with all city uta county oNlnancess and sort laws relating be
0 Wilding com ucdon. and hereby aulhorice mpmeenWiws of this city In enter upon Ne,
W shove -mentioned property fm inspection Purpose.
(We) agree to ave, indemnify and keep tameless the City of CupCr1MO against
cn Ilabilifinjudgmenu, com andctperse which may in my way accom against said City
ti z In consequence of the treating of Nis Permit.
nr
APPLICANT/UNDERSTANDS ANPIWjIa. COMPLY WITH ALL NON -POINT Issued bv:
• HAZARDOUS MATERIALS DISCLOSURE
Will ft applicant or future building occupant sort or handle hazardous malarial
m defined by tie Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(.)?
El Yes 'QNo
Will the applicant or future building =open, us equipment or devices which
it hazardous air contaminants as depend by the Bay Area Air Quality Management
Dlatric0
❑Ys
I haw mad the taraNms materials requirements underChamr 6.95 of that Califon
nit North Bety Cade,Secdom75505,25533§§d255M.lundersmndmatifthe Wilding
doesredy hewan¢mibility
to ratify the occupant of Cie
Re -roofs
Type of Roof
PERMITNO.
04120055
17111041' ISUE DATE
SANITARY OLP
BUILDING PERMIT INFO
BLDO ELECT " PLUMB "
D l�
MAR s?o 2005
�k i y.. , I� �.,1111
0
Required 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