00040135 CITY OF CUPERTINO ERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0004O/
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RC ITECT/ENGINEER BULUING I'ERMI'T INTO
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t_�'^ LICENSED CONTRACTOR'S DECLARATION
o i=c I hereby affirm that I am licensed oder provisions of Chapter 9(commeming Jo Description
F y t_w with Secdon]OOO/ofDivivion3of the Buaincasad Rrtosiom Cade,ad mYliccmeis n ./�/�//�edn� scr
s� './LI/ 4
asKin full force and effttt. S(/.�! /��0/✓ /Pe(Ng1' (.Ir/' (/"7l f/l. rj4(��
LiceLic.M v
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Q na nECrDECLARATIONPius Qva"
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OWNER-BUILDER DECLARATION
F r 1 herem sh
by affirm 1 son
m exemexempt from the Contractor'sI.iemse Law for the
f�O following..(Section 7031.5.Business and Professions Curie:MY city m county
nwhich reamme.person m mundane',titer,improve,demolish,or repair my awcmrt Ft. Floor Area Valuation
3- Prim to its issuance,dm recants IW applicant for such permit to file uigoed suitenhw•S, q
Net he is licensed ponwht m Ne provisions of Ne Conoactofa License law ICMper9 �O 66b
(commencing with Section 7000)of Division 3 of the Business and Pmicamunx Code)or APN Number Occupancy Type
that he is exempt Umrefrom and Ne basis for the alleged exemption Any violation of /-
Section 7031.5 by any•Pplicanl for a permit mbjects Ne applicant to a civil penalty of
pt more them rive handsel dollars(S500).
I,aarwnerrrtMproperty.mmyemPloym.witnw.geaa.mewmwmmpem,tion, Required Inspections
willdolhe wank,and theseacture is not incendedoroffered fm Wcum.7054.Business
said Rife iany u Code:The,Contractor'a License Taw docs cot apply to an won of
property star Wilds m impmva thereon.W who does,such work himself or,thmugis
his own employees,provided that such improvements enc rant intended or offered far
We.IL however,the Wilding or improvement is sold within one year of wmpledon,the
wmr-Wilder will have the When of proving haat M m
did hot Wild or improve for p -
pose
I,v t Me p of project
property,,B reclusively Professions with:)The, conactora to
construct in Neproject(Sm.rtty,aBuaincas and Protracting Code:)The Contractor U.
cense Lew docs not apply to h,owner of property who Wilds or improve thereon.end
ceho rise La docts for tapplytoatio wish wnacohtnnerts)licensed pursuantmthe Cemon.and
License Law.
❑I em exempt unmr 5«. .B&P C for Nis num /
Owner Dem
WORKER'S COMPENSATION DECLARATION /�
I hereby affirm under Penalty ty perjury ran of the followins declarations:
71h.as prowill eforby eCenifictICM of omem Me LaWo Chats.for
wohcis Compche le /
twat, r provided for by Section 3]00 of the Labor Cdr,for the perfonrunce of the
for whichlpeanut is issued.
d - s�1
I lute awill maintain Wrkch Compensation Imureme,u requited by Section tea/O
e37W of Ne labor Code,fate the performance of The woo ton which thio Remit Is ineve4. z
MyW tin urearecamcaand POILry
Carrier
. . PoIicY No.: re
.�ggu1.'L�E{t MPr10N FROM WORKERS'
/TMMUOWMAWAATION INSURANCE
(This wcdon duct becompleted ifthe permit it formerhudned dollsse(SI00)
or Leu.)
1 oy my Per in tin p y manner so s(wank for which this Me W is issued,Com shall
not employ any penin in any menrcr eco n m Wcrme eubjm to ton Wonken'Compen-
mfi laws of Cdifrmia.Date
Applili cant
NOTICE TO APPLICANT:IL alar making this C noires of M Labor Ca you should
hcchmr subject to Ne Workds Cions or
is earvi Mai of the labor Code,you must
fonhwiN comply wiN such provisions m this permit shall W domed rooked.
Q CONSTRUCTION LENDING AGENCY
Q IWreby affirch Met there is a crostmNon leading egancy for the Pcnfrmencea
Z the work for which this permit is issued(Sec.309],Civ.C.)
Undies Name
a j L<nder's AdGesa
Cil I mobil,Man I have read this application and rove Net the above information is
0. Q correct.I agree m comply with dl city and county ordinances and suite laws Waning lir
.� z buildmil onswcnon,and hcnby authorise repnsioundives ofthis city to enter upon Ne
U ibovemcmioncd Property for impactors purposes.
ks .lis (We)agree an save,indemnify and kmp harmless the City of Cupertino against
IJ liabilities,judgments,costa and expenses which may in my way aocme against mid City
�w W in metronome of Ne seating of this permit.
[� C. APPLICANT UNHERSI ANDS AND WII.I,COMPLY WITH ALL NON-POINT
UZ SOURCE REGULATIONS.
.w S,more of ApplicmUConuactor Dam
HA RDOUS MATERIALS DISCLOSURE
Will tWepplismtof future Wilding occupant stmem ladle hegudous material Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12.ad the Health and Safety .type of Roof
Costs.Section 255324)?
❑Yes yNu
Will Ne applicant or future Wilding occupmf use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit huudhus air crnuminsahs u defind by ted Bay Ane An Quality Mwgcmrnt installed. If a roof is Installed without first obtaining an inspection
District, Ia ree to remove all new materials for inspection. Applicant
C3 Yes sT.fNo
Ilurrrndfhch+urdouaCtJmateridaregninmmfaorder L,haaptrafi.95aftmGa,i- un erstands and will comply with all non point source regulations.
fade Health&Story Code.Sections 25515.25531 and 2553x.I understood that if the
WileinRdoeanact, ly hove at ant,that it is my respomibility m notify tie occupant
.f the rtqu e s�i�y��t�W�yp nm m igsuarce of a Ccp yyyto op yupancy -
/Y�t'} -16'la^�f-�/� �i'/OD/u/ Signature of Applicant Date
t w, ore orixd genes—��T Dam
\/ All roof coverings to be Class•,B"or better
OFFICE — -- —