00050119rY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ('�
I
p°oo
E i G "ani
Z
t- v LICENSED CONTRACTOR'S DECLARATION
.8R- 1 haraby afro than I son liceue l weld provision of Ch ser 9 (mm .1.&
tt9i with Section ]000)ri Division 3 of be Business ad Pifauions ode and my license is
y d j in full f«ce ad eRect.
w Lx- le Lic. N
3 F DemCmuacmr
t- u O g ARCHI'rF.CI'S DEC N
ert Ian be used u public meads
`d nn 7
w.00 hs' al
OWNER-BUB.DBR DECLARATION
C Y 1 hereby aKren that 1 am exempt from she Contrutor's License Law for the
iF O following mason. (Section 703 I.S. Business and Rafessions Code: Any city or county
ne
3 $ which requires a permit in, camera, alter, impose, demolish, or repair any Immune
prior to its issuance. also requires the applicant for such Want to file a signal statement
Nat he is licensed porous, to the provisions of the Contractors License Law (Chapter 9
(communis, with Section 7")of Division 3 of Jin Businw anal Pofeuioru Cods) or
that W is exempt therefrom said dm Wis for the alleged csemption. Any violdon of
Section 7031.5 by any applicam for a pemhit subjects the applicant to • civil penalry of
ns, mom then BvcWdrad dollars (3300).
I...nm of the popny, or my cmployen wib wages m b inolc a mpnsatlm.
will clothe work, and Nesmmu , is nor intended centered! for sale (See 7W, Buuna..
and P.ofeaxiom Code: The Contractor's Lianse Law dm am apply to an owner or
pmpeny who Wilds m improv. thereon, and who does, such woo himself or drought
his own employees. provided Jun such impovamrnu ale ma intendant or offered for
Wt. If. however, ba Wilding or improvement is said within arc ywrefcovmletion, be
oweer-Wilder will hove the Widen of proving Nat he did ns, Wild or improve for p«.
pose of sale.).
❑ I, as an= of the properly, sm exclusively conhuting with licenad contractors to
conswn the project (Sec. 7(106, Business and Professions Code:) The Convector's Li.
cense Law docs mt apply m en owmr of properly w W Wilds or improv. Norton, and
who canners fun arch pojecu was a convector(s) licensed pursuant to the Conhansma
anal law.
I am exempt.oder Sec. . B & P C feethis mason
Ownar Dau
WORKER'S COMPENSATION DECLARATION
sa.7 1 hereby
dur
amrm abler peny of perjury one of the following declautiau;
Fl I W. and will maintain a certificate of Consent to self-insum for workers Compare
rim, as prosidd for by Section 3700 of the Lata, Code. tannin pdamusce of the
wo f« whim Nia p«mit is issued.
1 nave Lawill aalntain Waters Compnwion weak
far which
u required t I Sadiron
J of be Labor Cade. fa the peed«manure of Uhc week rah which tNa permiturIsmail
�.
My Wnmeis Cempa�tie.de)«m.fa{ner ed PolicyMrAvgPf // rs C �I/
COMPENSATION INSURANCE
finis section rmd cad he complamd i(the pooh is faro« hundred dollars (5100)
«leu.)
1 cenify Wt in Neperfomunce of be work for which tits permit is issued, l sholl
ert employ, any parson in any mannar so as to become subject to the Women' Canpam
satins laws of caifami.. Dam
Applicant
NOTICE TO APPLICANT: If, after nuking Nia Cenifeam of EccmMion, you should
become subject to she Wms Compensation provisions of Ne "her Code. you must
farts dh comply with such provisions or this .it shall W deemed sevaked
CONSfRUC"nON LENDING AGENCY
Q lhembyMmJun We.commctianledingapmyfatheperfomunceof
Z the work for which this permit is issued (Soc. 3097. Civ, C.)
LendcJs Name
a 7 lam Address
hal1 unify that 1 have red this .,I,c.tinn and cam that the above information is
a. 0 rtcet. I aee grto comply with all cis, ad c ... I, odhan«a and sum Lws reline, 1.
r7 building building cwrcwdon. and hereby iuthim. rep.enan. of his city to mus, upon the
U 0 above-tamiamd MKOY fa inspection purposes.
k. F (We) agree to Use. indemnify end keep barmlw the City of Cupertino against
(, ).bill.., judgment, casual expenses which may in any way accae agues. said City
W in consequence of she grading of this Won.
❑t APPLICANI'UNDERITANDti ANI)WII.LCOMPIXWrrii AI.I.NON.POINT
U z SOURCE iEGUI. NS.
ai
Siga Applic Convect
NA].ARDOUS MATERIALS DISCLOSURE
ricJar applicant or tutu. Wilding occupant state or handle hamdms macriu
as dcfi.md by the Cuprtino Municipal Cade, Chopar 9.12, and the Naalth and Safety
Code, Section 25533(.)?
❑Yes
Will Jar applicants or future Wilding acupent vu equipmcm or devices which
coil haulms eu conaminanm in defused by the Bay Area An Quality Management
Disvic.? l
❑Yes pRvo
I have mad be Mw
uaras/nuansla re airemenrs order Char 6 95 of be Cali-
fomin Na.tm & Safdy Cade, Sections 25505, 25533 end 25536. I undo imm) that if she
buildin8 las caw cursyryY nave a c)f1nl, the is is mY rnpouibiliry to naifY t�c `�hia°i
G- Ppm
IaS�F�s�/�PQ�/�� �r/ e-
M,sn'rwr/1//— V�V'AI 0
Pick
Job Description
-77--,r'r
NIC
1-1
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 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