00050146OFFICE
CITY OF CUPERTINOt
BUILDING DIVISION PERMIT
CONTRACTOR -INFORMATION:
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NUILDINGADDRESS:
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UW iR'S NAME:
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LICENSED CONTRACTORS D LARATION
I hmby aPorr that I am licensed under provisions of Chapter 9 (commeming
Job Description
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with Section ]000)ofDivision3or rhe Buain.saM Profesiom Code, artl mylicenae is
In Poll force and effect.
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ARCHITECTS DECLARATION
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1 understood car plans shall W used. public reeads
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Licensed! Professional
OWNER-BUB.DEfr DECLARATION
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1he-by.— .(Sinn can I am exempt from Ne Contractors rex Licenu taw the
Any
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following rcasan. (Section 7031.3, Business and Rof.aiom Cudc: city a county
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which rtgoisu a permit to conswa, dter, improve, .1 .,it any swoon,
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prim It its iss... ce, dna requires the^pplicant for such point m file• aignedalatement
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Nm he is licensed Pursuant to Ne provismoo of the Common's License law (Chapter 9
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(commencing with Section ](100)of Division 3 of the Busimu and Professions Code).,
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the basis for e alleged exemption. Any violation or
dint he is exempt tha tiro m and th
Section 7031.5 by any applicant fm a permit subjects the applicant to a civil Finally of
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pm more Nan five hidned dollars (3500).
I.aso-wnamrdepropartr.mmremptoy..withw.gasasdevwlermnpewtit^,
Required Inspections
will do the work. aM the nrucoue is not inrtedetmofferect for We(S.. 7W. Business
and Hvfeadom Code: The Contractor's Licesue Law does na apply to an owner o/
property wW builds or improv« Ihrton, sod who does such wock himself or through
his own employ.., provided dun ouch insptovamrass are ret inrtoded or offered for
We. If, however, the building in impmvcment la sold within one yearof completion, the
ow.t-builder will hese the buNen of proving that h did not build or improve for Fw-
poseofaale.).
I, as most of the pr^Pcery out exclusively comtracting with licensed contractors to
osami a project (See 7W, Business and Pyofessiom Cade:) The Contractors U.
cense Law dao not apply to an ownar of pmperny who builds or iantrovn Norton, and
oopei)
..,itch
who contracts projem with n corn licensed pursuant to the Contractors
License Ls -
0 Iune.empimmu,ste. ,B&PCformisrcamn
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Owner Data
WORKER'S COMPENSATION DECUBATION
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1 hertbr.Rrtn undo paalry of perjury o. of the followingnatur
r work
of Coasrnt Wookcre Co
I leve andwilllfor
by eCenidwe rsede,forthe of end
time, as provided for by S.tion l]00 of the tabor Cade, loan the parfomuree of me
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work for Form, this pcmis issued.
❑ I have aril will maintain Workers Compensation Insurance. a equirod by Section
3700of the Labor Code, fee the perromu.e of rh work for which this permit is issued.
My Workers Compensation Inrvrmce carrier and Policy number art:
Cartier: Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This rc din nerd not W canplared ifthe mm n is forone hundred dollars ($100)
or less.)
1 certify that in me Performance of the work for which this p,mm is isnued.I shill
not employ any person in any manner so u m become stbject to the Workers' Conrpem
salma Laws of California. Dart
Applicant
NOTICE TO APPLICANT: if, 0. mddng this Certificate of Exemption, you "old
become subject tome Workers Compensation provisions of me Labor Code. you must
forthwith comply with such p o'hil .. Or this permit shall W diarist revoked.
CONSTRUCTION LENDING AGENCY
it. lcsding forth of
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Ihereby a n. dus care comerectioq agency Performi
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the weak for which this Fgnu{ rH 4AsOddl (Sec. 309]. Civ. C.)
rid
Landers Name/
lender's Address
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et de.ise mroun tion is
se tM
sand, that I have read Outs application endur
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I agree to comply with all city and county mditances and some laws eliding to
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building conautctinn. and hereby authomu rcpoeeenmtiv. of this chym anmr upon me
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aWvc.mantioned property for inspection purposes.
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(We) agrce to nava, indemnify and kap humins the City of Cu.m . against
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liebilitirs, judgunnt. cord and cepecoot which may in any way accme against said City
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in conxcqueae of the granting of this permit.
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APPLICANTUNDIMSTANDS AND WILL COMPLY WI'I I I ALL. NON -POINT
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tiOURCE REGULATIONS.
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Sigrum pplemr/C tan Date
HA RDOUS MATERIALS DISCLOSURE
Re -roofs
Will due .pplicant a fune Wilding Occupant store or hath, harardws material
as defided by the CupcNno Municipal Coda. Chums' 9 1, and the Health and Safety
Type of Roof
Code. Sean.. Z532(.)?yP
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All roofs shall be inspected prior to any roofing material being.
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Will the apFlicanc or future building Occ.pmt me egim mern or device. which
installed. If a roof is installed without first obtaining an inspection
shith.aodqusvi,...remix.oraasdefimedbytheB.,Ars.AirQualityManagement
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I a ree to remove all new materials for inspection. Applicant
and will comply with all non source regulations.
Ihave rcad the he]arduu mamriW rtyuimments uodcr Chapter 6.95 of de Cali
understands point
anomia Health & Safety Code, Sectiats 25505, 25533 and 2553x. I uderaud Nat if the
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ave a cent, it is mY respauibiliry on ratify the Occupan
Wilding docs not currently have meduan
rear u hi h I W ma prig m usua.a of. C am of Occupaey.
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Sign• of Applicant Date
Ownero rued agcm - Dam
All roof coverings to be Class "B" or better
OFFICE