00080044BUILDING DIVISION PERMIT
PHONI
ARCHITEMYENGINEER
LICENSED CONTRACTORS DECLARATION
t hereby atfsrm that 1 am IlereBu order Pd v fess of Ureter 9 my lken i is
with Section ]0001 ofDivision 3 ofshe Business and Ptofnsima Case. tial mY license is
fuIt foad o��ta.
eve Clclass_ g O�Lic.•
rce
c Conuactor
JJ ARCH SDECLARATION
�yfiden plans Nail ustd as public rewds
LLLvas
LF Pmfe small
OWNER-BUII.DER DECLARATION
1 hereby M. thin I un exempt from Ne Contractors License Lew for the
following reason. (Section ]031.5. Business and profess«s Code: My city «county
which m]aun a permit 0 cantruct, alone. improve, demolish. «teem my u -
Pd., ..is issuance. alto requires the applicant for such pemtit to tilt a sigvd smemem
that he is limosed Funuan to the prow m of the Contractors License Lew (Chmptem 9
(comtxncing wish Section ]000) of Divisco3 of she Busimras and Profeuiau Cade) or
Out he is comp therefrom and she buis for the alleged esempion. Any vioWi« of
Section ]031.5 by my epplicem for a permit objects the applicant to a civil s aloy of
not mom dm five hundred dollam
1, u ownerk. she property, os my irate eca wish wager Nei( sole compBw u
will doth work,ade: oisriai License Lawmdofor We(Sec.]044.Buai«as
and ProfwZ b Code: The Empower
th Contractor's License law tlnc trot apply self ower of
propeney coed builds at improve n, such real who does .acne wart hes) .1 orired e e
his own employers, provided that mors improvements tie cove intedd or plemar for
sale.ILMwe will
Wilding rimprovement issold within t ileo ertrnrove For she
ownrr-W ho.). will lave Uce burden of proving that M did not Wild «improve (« We.
Peru of sale.).
1. an, owner of Jce Sen. 71Property, am exclusively contracting with licensed comracmu -
ove La d project (Ser. ]04q wne, of
ad Profession Code:) The . tterm's Lid
who lawdocs neatapplytoan ownerofprogenywce Wild «iot-the Jrmn.ad
who r«tracB for such projecu with a conuanor(a) licensed purswnt to the Covntrectors
an Law.
0 I em cxempe oder Sa. . B @ P C for Nis recon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury me of the following declarations:
❑ I have ad will maintain a Cmiflestc of Covent to calf -insure fo Workers Compon-
W ine. as Provided fee by Section 3700 of the IaWr Cade, fon the Performance of the
work for which dais permit is issued,
1 have and will maintain Worker's Compensation Insurance, as required by Section
3700.1fJte labor Cade, fa the perfovrrv«e of the weak for which this Permit is used.
My Wofkera Compensation lnsura«c carrier and Policy number me:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Ibis section «d Out be completed if the Perron is follow hundrd"Ima (SI00)
or less.)
1 certify Nat mine «Hormmceof the wok for which this pomth is isued, l shall
WE employ my peram in any manar as u to Woonse.mbject to the WorkerCampm-
ution laws of Califurrim Dace
Applicant
NOTICE TO APPLICANT: If, after making Nis CcniGeine Of Exemption, you should
become subject to the Worker Compcuution provisions of the Labor Celtic, you must
foMwith comply with such provision or this .it shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Q I hereby affirm that Vert is a concoction lending agency for the perfomumce of
Zthe work for which this permit is issued (Sec. 3097. Civ. C.)
Ledels Name
0.a Iandcrs AJdrtsn
Ly 1 certify Jan I have read this application and stale that the above infomamon is
L z torten. I agree to comply with all city and nnca county otdiand 'into laws relating l0
z building cantvetion. and hereby sudwriu represeautiva of our city to enter upon Bs
�! 0 above-memlmaA pmpsny for inspection Imposes.
La. (We) agser to save, indemnify and kap harmless the City of Cu«nino against
LF.7
liabilities judgments, costs and eaponus which may in my way accrue against laid City
} LTi in «nsrq«ret of the granting of Nis permit.
E� 96APPLIG\'f UNUIiRST D ANIl WILL COMPLY WITiI ALL N(IN.PoINT
f..% Z SOUR NGUTA'iI
St ur Applicmt(Comnctor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant store or handle haeasdous material
u defind by the Cupertino Municipal Cdc, Chapter of 2, and the Health sal Safety
Code, Section 25532(0]
O Yes ON.
Will she eMli'mt or future Wilding mecupant use equipment or devices which
mil hasardo is nor communities u defined by the B ty Aran An Quality Mmagcmcnt
District?
C Yes rho
I have read do hasudout ="all nuuitcnrm udof Clalacr 693 of Je Cali-
fornia Heal A Safety Cade. 25505. M533 ad 25534. I udrnund that if Jte
Wilde ria current) , rnanktha, it iy�ty res'niubday to notify the«cupnt
t of drer«nb w be in prim t ante of a Certificate of Occupancy.
SCHAUMANN PLUMBI
L 1455 LAURELWOOD
(408)986-9044
Re -roofs
Type of Roof
AND
Job Description
SERVICE UPGRADE
7 77 3 2Zg
❑ IO8/O7/
304 — ROUGH ELECTRICAL
501 — FINAL ELECTRICAL
505 — FINAL ELECTRICAL
ENERGY
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