00060023`e int n DING DiviSION PFUMIT I CONTRACTOR INFORMATION:
ARCHITECTIENGINEER:
LICENSE) CONTRACT OR'S DECLARATION
1 herehffi
y arm dem I mn licensed under provisions of Chapter 9 (commencing
with Section 700(B of Division l artist, Basins,,and 11rnfcsiam Calc, and any license
' 1 in full little and
One —
ARCHITECT he e n S IIECLARA'1 V
I understand my plain shalall M1used as public hands
Licensed Pmfeminwr
OWNER -BUILDER DECLARATION '
I hereby aftimt that 1 a enmt form se the Contractor's LicenLaw for the
following reason, (Section 70 eBroinesx and Professions Cor Any city or county
which requires a permit to mnaruct.: lu r, improve, demolish, or repair any slrucmre
,noro, its Ix,owov. uho rcymrt,, the applicant lot such permit uh EIt, a signed oale neat
that he is licensed Pursuant uh the provisions of the Contracml, Liecow Law (Chapter 9
brnmmencing with Section 7010) of Division J of the [fastness and Prefessinns Codd
or that he is exempt therefrom and the hasis for the al le" exemption. Any viola ion
of Scdion 70115 by any appli,a t for a pconit subjects the applicant to u civil penally
of not msec than five hundred dollars IS5Pd.
01, as owner of the pmpeny, or my employees with wages as their sole compensation.
will do the work, and the nnicrum is not intended or ordercJ for sale (Sec. 7014,
acininnod P...Ic, int s Cck: 9'he Contractor License Law docs not apply lit an
r oc f property Whoto
bnuim
d. or pmcra
v, Ibam, and wLo din
ocs ch work hinswif
or ihmagh his own employee%, ymvided that such improvements arc bat intended or
ordered for sale. If, however, the building or improvement is sold within one year of
completion, the owner -Molder will have the burden of proving that he did not build or
hnprove no pmpfar ,c of sale).
01. as owner of the proper, am exclusively contracting with licensed cophucnm to
construct the project (Sec. 7614. Business and Professions C(xk:) 'Oe Contrall
License Law dans not apply lit an owner of property who builds nr improves Rive ,
amt who Contracts lot such projects wish a ummouunm) licensed pursuant to the
Contrast, s U,O w, Low.
01 am a car, under Sec . 11 M PC for dist, reason
Owner Dom
WORKER'S COMP( NS6nON DI!CLARATION
1 hereby affirm under Penally of perjury one of the following deelarmimrs:
,] I have and will maintain a Centres¢ of Consent to self -insure for Worker's
C upcbsutiun, m pnrvlded for by Section 1700 of the Lubar Code, fur the
KI
of the work lot which this pcnu l is issued
(V .
I have and will mamphm \Yorker's Compensation Insurance, as required by Section
370 of the LaMn Ceder, for the Mrfommant, of the work for which this Permit is
issued. My Wurlo r'sFgmpemntion buurancc canter unit Put icy brother are:
('ILi, sedan need not be ennplered it Ilia permit is filo one handed dolhnx
15100) or less.)
I cenny that in the perfome nce of the work lot which this Permit is issued. I
shall nm cannily any person his any ..amber "n us Io hemp" "-nice, in the Worker*
Cabghcrosaniun Low" of L'alilbrnla Dane
Applicant
NOTICE TO APPLICANT. If, cher making this Ceri ficme of Hu mptien, you ,would
hecome suh,cl ,, the Worker'. Cnmpenvhinn provision" of the Labor Cole, you now
funhwith comply with "hath provkiobs at permit shall be deemed revoked.
CONS'rRUCI ION LENDING AGENCY
I Ilemby M. that there is a cnnswetion lending agency for the perfontance
of the work for which this pmmi, is issued (See. 1007, Ci, C.)
Len'I'l N, up
Lender'"AJdress
I certify that l have read this application and "tate that the above information is
acct I agree to comply with all city and county ordinances and state laws relating
nh building ounxnuction, and bareby aulhnrise mptwcnm ot%of this city m enter upon
the above-nmmionnl Pro,l Ibr imsnui puqunnax.
(W'e) agree Io sa, indemnity and keep harmless the City of Cupertino agents
liabilities, judgments, casts and expense" which may in any way acerae agaiml with
City in cabsequcna: of the granting of this permit.
APPLICANT U DE DSANDWI .COMPhY WITH ALI, NON -POINT
SOURCE N/rj7�/",L 'IONS -- spy
Sigmm�renflpplicanVC mmcmr DA
HA .ARDOUS MATERIALS DISCLOSURE
Will Ilse applicant or hums building occupann stare orbeitile hazardous turnout
o" defined by Ibe Cupcnlno Municipal Crate, Cbupwr 9.12. Ind the Heald, aid Safety
Code. Section 25532(u)7
Will theapp] eamt of Iaue, ho lb ng occupant use equipment or device" %Inch
"til hnrordous air contmniban,, as defined by the Ray Area Air Quality Stunsgement
strkr
❑Yo Iw
wry I Dol. NO,
s n�
11LIN3 ELI iCr 1'LIIMIt n V Ml:CII
IJ I-1 f—'1 r=1
RE—ROOF Job Description
305 —
FRRMVZeyaired Inspections
307 —
INSULATION
601 —
ROOF TEAR OFF
602 —
ROOF PLYWOOD NAIL
603 —
ROOF BATTENS
604 —
ROOF IN—PRO RE
Issued by:
Re -roofs
Type of Roof
Date` � 7
All roofs shall be inspected prior to any rooting 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. •
I hoc read the ha,ardons mu.coal, regmramea,x ander Chupmr fi,95 of the
Collfnmlu lkahhk Surety CnJC Sectinns255o5, 25561 and 25514.Iumdcrn..i
no,
docs nal curnnllyhovea¢nam,that itis. myrmp ics, of ityethernthe V S 00
arupam of clic is x�hich m a fx sen prior Io issuance of a Ccnincam al
Deaaparcy' �n I , z / /_r I Signature of Applic: t Date
All roof coverings to be Class `•B•• or better