04120021BUILDING DIVISION PERNUT
BUILDING ADDRESS:
PORTAL
I Ilmeby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Smolon 700(fiof Division 3ofthO Real •• and Podlessium Code,and my Iicemeis
In full farce and effect.
License Clue - Lm.0
Dau Comment,
ARCHITECTS DECLARATION
I undmme nd my puns shall be used an public reCords
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby alTirm that I am exempt from die Convenors License Law for the
fallowing mason. (Section 7031.3. Business and Professions Code: Any City Or coumy
which requires a promo to construct. alter, Improve. demolish, or repair any structure
prior to its Issuance. also requires the applicant for such permit to BIO a signed sutement
that he is licensed Pursuant m the provisions of Ne Connector, License law (Chapter9
(commencing with Section 7000) of Division 3 of the Business and Profwions Cade) or
Nm he is attempt dearcfree and tee basis for the alleged essmptlon. Any violation of
Secdon 7031.5 by a" applicant fon a permitsubjau the applicant to a civil penny of
not roam Nan A. baedred dollars (5700).
❑1,no ofdupropenymmymployms Lb"geuft4wle mpm Wm,
will do the work, and Ne awnure isnot intended or offered for sake (Sec. 7044, Buslrcsa
and Professions Code: The Conuanofs Liana Law dors not apply to an owner of
property who builds ar improve thereon, and who does such work hin o d f or duough his
we employee. provided that such Improvements ase notimended aoffered fmaam. If,
however, the building or improvement is Cold within one yam of compledan, the awnm-
builder. will have dm burden of proving Nn he did nes build or improve for purpose of
eOmer of du property, am exclusively convecting with licensed contractors m
eo Ne prej= (Sec 7044, Business and Profnsians Cade:) Thr Conuamrs l.1
sense Law den not apply to an owner of property who builds or improv usreon. and,
who conuams for such projects with a comoscus(0 licensed Woman, se lie Conuacmra
License Law.
C l em exemot und¢Sec. . B& P C fm Nie won
I hereby affirm under penally of perjury one of the following decuntiuns
DEMO
I haw and w01 maNuin • CW Oram of Come¢ roself-edam for WarkeraCmPen-
on, u provided fee by Sarson 7700 of rite Labor Cade, for the performance of Ne -
rkfeewhichNisperrouisissued. - — - - -- -- --
1 haw and will msiream Wmkers Compemadon I.ce, as required by Section
XI of the labor Cade. for use performance of Ne work fmwhich this permit is issued.
Workers Compensation Insurance Carier and Policy number tee:
COMPENSATION INSURANCE
section need not hocompleted HUN Permit is foroae hundred dollars (SIM)
I cenify Net in the perfor manor of du work for which this Permit is issued, l shall not
employ any person in any Cumar an as at Ixemtne subject to the Workers' Compensation
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
berme subjcm to the Worker's Compcuadon provisions of the Lahnr Code, you muss
,J Q forthwith Comply with such provisions or this permit shall be deemed revoked.
„zy ~CONSTRUCTION LENDING AGENCY
[-+ I hereby affirm that Ncre is a comwcdon lendingageacy fat the performance of
f� .moi the wurk for which Nie permit is issued (Sec. 7097, Cie C.)
W Q Landers Name
Dz Lender's Addw
V Q 1 modify dal I haw read this application and sum that Ne show infomadon is
it, !w comet I agree to comply with all city and county mdlnmm, and emus laws Rlaling m
Lei! building Construction. and hereby euNorim reptesmuuws of this city m enter upon the
W abuw-mentioned property rot inspection purposes
gy (We) agree to save, indemnify and keep harmless rite City of Cupertino against
rn Ihbillllm,judgments, costs and caption which may in my way e=me against said City
V `1 In consequence of the granting of this permll. -
�i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
RnIIRCP Rrmn.annNS _ r
HAZARDOUS MATERIALS DISCLOSURE
Will du applies, or future building oaupantst=¢handle hanrdow material
������ppppppececcc�BB�00nod by 0te
Cu no Municipal Code. Chapter 9.13, and the Health and Safety
p sic,
Will the applicant or future building Occupant use equipment ser devices which
mit havardous air eortoutan0 as dcrined by the Bay Area Air Quality Management
District?
❑Yesu
Thaw reed the hvmd=materials requlremw eunder ChepmrQ95af the Glifor-
AHealth &5afmycode, Such= 25505,33533 and 75334.1 underwnd don lithe building
doe not currently haw • umpy) mm Il -4 my ramence hity to nod fy the occupant of dr
Issued by:
Re -roofs
Type of Roof
""04120021
Job Description
3 5 0 0
Valuation
""✓(��'\O`ccup'ancy Type
VV
Required Inspections C
C"
All roofs shall be inspected prior to any roofing material being installed. i -, _ _.
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