00030091rY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
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nem
Qat',
LICENSED CONTRACTORS DECLARATION
O h — 1 hereby afrum that 1 un licensed under provisions of Chapw 9 (comnrrcung
Q=Cw with Section7")IffDivision3oftheBminess and professions C{aQc. dm
Z y Me j in full folce and elfcc, a /6
Me License Cles lie 0
p a.
s� 3 0 Drew Conusswr
r u: O g ARCHITECTS DECLARATlO
I understand my plans shall be used v public recalls
wa O I-ieenxd Professional
c uNj o v, OWNER -BUILDER DECIAMTION
I hereby aTirm Out 1 sum exempt from the Committees Licem a Law for the
D following reason. (mon 7031.3, Business and Prof ions Coa de: Any city county
w m which "soma a permit to cantruct, dter, improve, demolish. or roped, any swcwe
prim w iu iauance, also requires the a,Iic. fa such permil be Mo. si'med tawment
that he is licensed pursuant to the provisions of the Connotations License law(chapter 9
(commencing with Section 7000) of Division 3 ofine Business and Professions Code) an
Nat he is exempt therefrom and Om basis for the alleged exemption, Any violation of
Section 7031.5 by say applicant for a permit subjects the applicant to s civil Pendry of
not more Nan rive hundred dollau (5500).
I, as owner of the property or my employees with wages u their sole compensation,
will do Ne wok, and the tructme is nm intended or ofamed for We (Ser. 7046, Business
and tiofesdotu Code: Tlhc Cwtrxtoi s License law was docs t apply to an owns M
property coed Wilds or improves thereon, and who don such work himself in through
his own employers, providnd that such imponot s are trot inteMal or wilered fa
sale. If. however, tad Wilding or improvement is sold within one yavofcon,leuon, lb,
ownenbuilder will have the burden of proving that be did not Wild or improve for per
M. ofade)
I, as owns of the property, am exclusively convecting with licensed contractors in
construct to project (Secs tfNb, Rminess and Professions Cale:) Thu Contractors U -
cense Lew does not apply to an owner of property who Wilds or improves thereon, and
who contracts for such pmjmm with a commands) licensed purswnuo the Contrscto's
License Law.
I em.rola under Sec. . B 6 P C fm Nis taxon
Owner Date
WORKER'S COMPENSATIONAR
DECLATION
1 thereby affirm under penalty of perjury, oat of the, following dccWations:
I have that will maintain s Ceri fiame of Co.., be self -insure for worker's Conpen-
,mloe, as provided far by So e. 37W of the Labor Code, fa the pehfareana of hue
wok for which this permit is issued.
❑ 1 have and will mountain Workces Compensation Insurance, as required by Section
3700 of NC Labor Code, for the perfurmvicc of ted wok for which this permit is issued.
My Worker Lamoen et w IhMRnc�e cmritt and Policy n1zlp12 w..e /7�
Comm: }�h1YAlY/l7 policy No.: /T�'I 'I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
!This somon moment becompleted ifthn pcmdt H foorohundhedl"Is , (5100)
an less.)
1 ccnify dust in the pedomerce of the wok forwhi,h this permit is issued, l shill
not employ any person in any maaur an as to become subject to the Worken' Cone on -
more Laws of Cdifomia. Data
Applicant
NOTICE TO APPLICANT: If. ether making nox Ccrtifcate of Hxmnpdon, you should
become suh*t to the Workers Compensation provisions of the Labor Code, you most
,,, with comply with such provisions of this permit shall W domed revoked.
CONSTRUCTION LENDING AGENCY
I be aby affirm Ow there is a contmcdon loading agency fa thin p nfomurcc of
Z 2 the work for which that permit is issued (Sm. 3(197, Cie C.)
4 Lendch Name
oF4 > Landers Addre,t
W1 mon', that 1 have read thin application it awe tht we above information is
M., z correct I agree to comply with all city and county mmusincn and suss laws relating in
;D tibuilding mintme on,andhereby tuthoriu rtpteonutivea of this city to emer upon the
ebovcmemioned propety for inapiTtom purposes,
kt tw (We) agree to save, indemnify and kap harmless the City of Cupertino against
[) Liabilities, judgmems cwt and espenos which may in any way seems agsintt said City
�., W In conoqucac of the Bmnung of this peonot.
[� 4 AVVLI- NT UNU5-t-,
iHS'1\NUSANU NII,h CUMPLI'WITH ALL M1'UNI'Uljjj-1'
S(lUN ai FB . I'I t. �"� f
� z 3 ! /C�
Signa rt of Applicam/Conuacto >re
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding w'cupant store or handle historians material
as defined by the Cu(T)mno Mumc al Coro.
chapter 9.12, end the Heath and Safety
Cada Sa9on M532(a)7
❑ Yea ; Nn
Will the applicant or future Wilding occupant use equipment or devices which
mil hazardous an Coulson u a`pefinM by the Bay Arca AG Quality Management
)ituia7 SWJ/
0Yn No
I have mad he hazudeus manorial. requirements under CTupter 6.95 of the
fomin He" #�6--
tans 25503. 25533 and osibi I aato , th
WildinBd pcnve ¢n��n that is it rend 2553lllty to understand
reptant
of ULA l �C hay- prima usoe of a Cmuf1"te fOwhmror u0wriznd agent �w"�f/ D.
p D- /3or
�Yia�-nna 83533 ❑
S31
Job Description
44u ukti� Ffew�
Sq. Ft. Floor Area
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 aggree to remove all new materials for inspection. Applicant
undersn ill comply with all non point sourc regulations.
3
Signature of App (cant Date
OFFICE
All roof coverings to be Class `B" or better