00020068TY OF CUPERTINO
BUILDING DIVISION PERMIT
LICENSED CONTRACrOR'S DECLARATION
I Araby aRren tat I w licamed under proviximt of Chapter 9 mrsh menus
with Section ]pp) of Division 3 of the Bminess and Prohobm Code, and my liana is
in full force and eR
Liceese Cta Lic. N
Date Convuwr
ARCHITECTS DECLARATION
I wdeamnd my pilots shat be used as public rccad,
Licamnd ProfloutrW
OW NER.BURDER DECLARATION
1 hereby uifirm that I sm exempt from the Contractor's License Law For to
following ... (Section 7031.5. Beni=ss sed Profusion. Code: Any city or county
which agoues a permit b comwar, alta, improve. demolish, or rep fir any ...
prim to its romance, W. requires to applicant fa meh permit w rent. •.igred I9deaunt
that he is licensed Formant to the provisions of the Comwme. License Law ICheptcr 9
fcommenclag with Section 700))of Division 3 of to Business and Pimmusiom Code) in
that he is exempt Naefram and to basis for the allcgW exemption. Any victim. of
Salon 7031.5 by any applicant for a pmnit whiam ra applicant to a civil penalty of
nm mom Nan live hundred dollars 45(1)).
I, m owna of res properly, or my cmploym with wages u thou wee cmnpcn m.
will do Ncwmk, Coe: orComiaoat isct..Lawclofor de(Sa.]WnownereOf
and arty whom Code: lure Conwcmr's Liame law alas nes apply ro lf owner of
his nY who build., p irnprovn thsuch Improvements and who does ruck work himself i thrimeed for
his own employees, provided Net such inisidw are nm intendedrfce oHemi, for
owes If, Mae,to building l era prment is sold within t yearofcompletion, the
owashe., witaeNe burden of provin8NaobedidnotWiklaimrpmvefmpro-
pose of ole.),
m I. u owner ej ci property. ,Bead and contracting with ached Contractor.
i.
coma=t Ne acorea (Seeapply
]area, wner of and property
who
Cade:) The Ganmecwrl IV.
censeLaw daonotapplytoan ithaa/property who Wildaorant to vu Namoa,tib
who contracts for such project with aconvacmds7li<emed pursuer m the Cantnmors
Dano law.
❑ I em exempt under See. . B A P C for this ratan
Owner Dat
' WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of amt., . of the following Eaclantiom:
o 1 have and will munuin a Cenif<ate of Consent to olRinsure for Woher's Compere
tioar u pmvidW fee by Section 3700 of the labor Cade. fee the perfomar. of the
Xo k for which this permit is issued.
1 have and will maintain Woos/s Compensation Imucaroc, m required! by Section
]Oo of the, labor Code, he
dm rfomwoe ofdc workforwhich Nispeomituiscued.
My Wm Comamuum ranee em and Policy gym=/ 3;
Cartier c .Policy No:
CERTIFICATE OF EKEMPIION MOM WORKERS'
COMPENSATION INSURANCE
(This section need nm he cnmplarnd dNe permit is form= hundred dollen ($IN)
or Ica,.)
I unify tat in the peforma=e of Nc went for which this permit is iswed I shall
not employ any person in any manner so as to become whim' o the Warkere' Compen-
sation Laws of California. Dam
Applicant
NOTICE TO APPLICANT If, after muting this Certificate of Exempuon, you should
become mbjat to to Wmkels Compensation provisions of to labor Cade, Year must
forthwith comply with ouch provisions m Nis permit sell be demand mvoked.
CONSTRUCTION LENDING AGENCY
I hereby oRnn that there is a construction lending age=y for ted pafanm=e of
the work for which this pemut is iss=d (Sec. 3097, Civ. C.)
lender's Addmic
1 certify that 1 have read this application ..it in Net the above information is
oat. I agree to comply with all city aced coney ordinances and Rule laws mlaung in
building cmmmctioo, and herby wNorior tamcmnmtives of illi, city m rnter upon the
above-mentiuned pmpeny for inspection purpam.
(We) agree to ave, indemnify and kap harmless the City of Cupertino against
liabilities. judgment. cru en
u and expenses which may in any way seems against said City
In mum,ple=e of she gmming of this permit.
APPLICANT UNDERSTANDS AND W 11.1. COMPLY Wit 0 ALL NONdroINT
SOURCE REGULATIONS.
sill.of Applican Con ctm Dat
h RDOUS MATERIALS DISCLOSURE
Will the applic or lower building meoprm nom or handle haeacdaus mamrial
It alarmed by the Cupertino Municipal Code. Chaim 9.12, and the Heald and Safety
Cade, Section 255321.)?
❑Ym
Will the applicant or future Wading Occupant use equipment or deniers which
emit haardous air Imiamimnt as deflned by the Bay Area Air QW ity Ma=gemem
DIRVItI[
❑Ya A11ef.
I ave mud use muni m materials m sliremcnt under Chapter 695 of the Cali.
fmnia Health & Salary Cade, Sntiom 25505.25533 and 25536. I undvstand ted if the
Wilding dm not currrnfly have a la=m. that is is my lupmnibilily to csify, the re ufam
of t1ie gguirenWs whiylj must be met prior to nsumce2f a Ceniraam or Occupancy.
CONTRACTORINFORMATION: �O Ol l—
/�/A/ S A Nil ARY NO. APPLICATIONSUBMII-.
/13 c -o , NIC CONTROI.x
Job Description
to
O
�6'v
3 99
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 agTee to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of Applicant
OFFICE
Date
All roof coverings to be Class mB" or better
INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE INVOICE
CITY OF CUPERTINO
BUILDING PERMIT INVOICE OPERATOR: chrietya
Sec: Twp: Rng: Sub: Blk: Lot:
INVOICE DATE......: 02/11/2000
REFERENCE ID # ...: 00020068
SITE ADDRESS .....: 21251 STEVENS CREEK BLVD
SUBDIVISION .......
CITY .............: CUPERTINO
IMPACT AREA .......
OWNER ............: CITY OF CUPERTINO
ADDRESS ..........:
CITY/STATE/ZIP ...: CUPERTINO,
CONTRACTOR .......: LIC #
COMPANY ..........:
ADDRESS ..........:
CITY/STATE/ZIP .... ,
TELEPHONE ........:
FEE DESCRIPTION CHK TOTAL FEE PAID -TO -DATE BALANCE DUE
_________ ____________ -----------
0.00 0.00 0.00
0