00090191BUILDING DIVISION PERMIT
BUILDING ADDfl£4Y.
V,31 Ill HV
OWNER'S
F N � LICENSED CON'TRACTOR'S DECLARATION
Z y _ O I hmnhy aflirn, Jtat [,,,,I licenced under provi'tnnx of Choicer 9 (commencing
Fo,,r.J wish Section 70(10) of Division 3 of the Bminms and Pmfmsiom Gde, and my license
m ^ is in fall pace and effect.
s e a I.Iceme Clasx Lit.4
O U L', Commator
m i a+ n ARCHNECI'S DECLARATION
< I undcntan l my plans .hal be ml as public accords
g r
+I p re LicrnaeJ Prolcsxinnul
p LL flW' N EWI HOLDER am the RST omentON
— I hereby alTnn aha 1 um exempt fmm the Commanr's License Law for IM
C Z < Inlowing reaxmn. (sealon 7031.5. Bmfnas and Professions Code: Any city or county
E x o which mcp,ircx a pernit Ill mmnmcl. ahcn improv,. den oh,lb. or repadr, tiny suucmrc
taad3m prion its ixauani... requires Ill—Iii lor.ncb perm..... Glc asignedammnmnt
mat he is licensed punuanl n, the pro, s of the Commaor. License Law (Chapter 9
(commencing with Section 70(10) of Division 3 of the Bminms and Professions Cale)
of Ihat he In uxc, I Ila,mrotn and the basis fur Nu :dlegcd exemption. Any violation
ul'Section 90.115 by tiny applicant Or a pera,it sahjecu the lophnml m a civll Icnulcy
of an marc than five hundred dollar, 05(10).
❑ 1, os owner of the pn,peny, or my anploycm .in tallies as their sola compem.fion,
will do the work, and the III ntlore i.InlenJcd n olrcrcd lot s.& (Save. 7044.
h
Iainew tad Profroimu Cale: The Cm loolur's .untie Law doe.. Dol appy , as
orr of property Who build, or impel Nicene, and who docs such work himself
inrough his Own employees, provided that tach improvements arc not intended or
011ila. lot .vale. If, howcvcr. the h,:ddiag nr improvcnmtn is sold whhi. one rear or
m,pletion. the owner badder will have me barren of moving that be did Dol build or
improve for purynm of eale.l.
O 1, as toner of the openYalit exclusively t N with licensed contractors m
+q I II ' j I (h 7044 II .ex cial Ptolt,sor, C I,:) I It, Collooli
L ciao 1 -am doe,can appy to act axerver of fmotrec, )III huild inTi flicarm.
and %he commex for Inch p) t wall a smabractors) licensed moment h, the
Conlr I '1' setae
❑ 1 a,ll axentpl ander Sec. . B A, P C for this u.an
Owner Date
WORKER'S COMPENSATION DECLARATION
I;(SI00)
I heresy af0rnt underpenally of pe.inryoncol Ilea tollowing danlorncionx.
7 1 have and will maintain a Certificate of Cement m xsIJ-mmre for Worker's
Compensation, as provided ln by Section 3700 of thlabore hor Cotte, for the
vatlunanmcar me work lin which thin pcmdl Ix❑ 1 have cant willnecinmin Wndcr's Compensation Imamate. as required by Section
37W of the Labor Cods,, for the performa,ce of the work for which this permit is
'.Sled. My Workers Gnncmation Imunmu carrier ad Policy number arc:Carver: Policy No.:
CERTIFICATION OI' E%CMPDON FROM WORKERSCOMPENSATION INSURANCE
(This cation need not be completed if the permit is for one hundm0 dollars
or las)
I army than ill the perlammnce of the work far which lhi. permh is issued. 1
shall Dol employ any peon in tiny manner a+a' to become 'officer n, the Worker.
Confetti ion Laws of California. Dae
Applicant
NOTICE'I O APPLICANT: If, enter making aJ. Cenireae of Exrolni—, vmt'hoold
becmne'object a, The Workers Ca:++pensa er, oo,kiom of the Ichor Calc. yon I,.,(
D C fonhwilh comply with such provisions ser this permit shall be deenmd revoked,
zCONSTRUCTION LENDING AGENCY
I hctrhy al8rn that bete Is a 1onMmcti.... lending agency for the pertam+ance
of the work In, which chin pemil i. I ... call (Sce. 3097. Ci, C.)
0. Q Lender's Name
Z Loader',. Address
U 0 1 certify far I have read this application and stale that the above iick amaction is
Gr. E.. cornet I ..gree to comply with all city and county ordinances and nom laws relating
Q O to huilJing connmtction. and hereby noncom represiontivc.uf aria sit, u, call upon
Nc ahovatncnciotmcl prop9ry far inspcctinn pnq,oas.
rt�,t d
(We) agree It %aro, indnnnify and keep harmless the Ciy til Cupertino against
W liabilities, judgmems. cont, and expemen which may in any way acme eguina said
U z
Cry in mmrx,mmi ,I he gmming of chi, permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
Scimitars, of Appheam/Cmlmaor Dae
IIAZARDOUS MATERIALS DISCLOSURE
WIII clic ali I ser fumm Madding an+punt.aomorit ndte hmanloa. mamrial
as defined by the Cupertino Municipal Coda Chapter 9.12, and the licallh and Safety
Code. Scene. 25532(al^
D Yes ON.
Wise the nppllnml or marc bus.Bing a¢apuat lose cgnlpoor a a deri'v, which
emit hr,ardois air contaminants as defined by the Bay Area Air Quality Management
Din imp
i ❑Ycx ON.. ,
1 have read the hamrdo w anterial, mstmarn¢n1s under Chapmr 6.95 of he
5lifomin Health & Safety Calc. Sections 25585.:5533 and 25534. 1 understand Ilea
if the hniiJing docs not curtently have a tenant, that it is my cexpmxibility to notify the
euptt ( of the mptimoli which tnmt be mel prier m isxoancc of n Cen.Eeme of
0wner or seal red agent Date
CONTRACTOR INFORMATION:
WATER HEATER escription
Sq. Ft. Floor Area
APN
NO.
PLUME MHCH
502 — FIRU WrdalblkylKfcfti(ME ENERGY
506 — GAS TEST
507 — FINAL PLUMPING
43
Issued A
Re -roofs
Type of Roof
Date
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.
Signature of Applicant Date
All roof coverings to be Class "B" or better