00040189BUILDING DIVISION PERMIT
LICENSED CONTRACTOR'S DECIARADON
I hereby aRrm than 1 an
licensed under provisions of Chaffer 9 (commerving
with Satioa 7000)offrvi.sion 3.f Be Business anal Professions Code. and my license is
in full force and eget
License Clean Lich
Data Conmdhr
ARC"nTCTS DECLARATION
I undmrW my plans "I Is, used u public annals
Llcammd Pmfesa mol
OWNER -BUR -DER DECLARATION
1 hereby a0irm dant 1 am exempt from the encroaches License law for the
following mason. (Section 7031.5. Business and Prhfacica s Cade: Any city or county
which rectum, is permit to entowa, ape, improve, demolish, m sepal, any [wm«e
prior to its issuance, also requires the applicant for such permit to file a signed statement
dot he is limnsed punuanuo the provisions of the Contractors License Iaw (Chapter 9
(or mmenring with Section 700(1) of Division 3 of the Bmineu and Professions, Code) an
that he is eurtq.t therefrom and the basis for the alleged cumption. Any violnims o1
Sutton 7031.5 by any appficam for a period subjects the applicant to a civil penal
t more than Eve hundred doilm ($500). (a y
I.asownaof Nepmpny.wmyemploye swiNwagesu Weir sole compcw
will Prfewmk, andeve heCortarenf Um. "a, doe«isle(Sec.7046, Busineu
and Pny who
Code: The Contractors License taw docs n« apply s lf owner nd
progeny who builds or improves Merton, and who d«a such woh himself . or enough
his own employeee provieed r such improvements are col intended m oleemd for
isle. ILhowever•Nebuilding ran apenvem issoldwithin oneyenof r impenletfor rhe
owmr-0uilacr wall n.re Ne burden a proving N.t h<did rent hada «improve for pr.
pone of sale.).
st as owner of Ne Soct. 7 y, am exclusivelyand convecting with licensed Conno-anon i-
construct the esprojectpply n an Business andy.1rprofessions Wi daer:i The Contractor's red
who taw does wt applyonan owner of property who builds or improves Nmm�, and
whochnrassfasuch project with aconvacmr(s)licensed pursuantwthe Conrecroes
I erose few.
❑ 1 um exempt under Su. . B h P C for this reason
rmltml l NO.
pl
M�u //ate
ANITARY NO. `iAPPLyC A�Oi
�� N Com RC
46
6 w 9�L l it l BOLDING PERMIT INFO
Job Description
I
Sq. FL Floor Area ation
-
�,a06,rzEss
�•rner Code
r WORKER'S COMPENSATION DECLARATION
1 hereby ill mai under, penalty of e perjury one of the following declarations
ima:
QIhaveand will fwbynaum 37arofCe Use heel ,forture forffoe aofthe
I utirm, e, provided fpo by Section 3700 of Ne labor Cade, for the pRomunm of the
work o whichthe, permit is Tuned.
❑ I nave and well maintain w«krrs came niche w Irwruwhi u required t i Sectionm
3700.fthe Labor Cade, for numusle carrier
work for which Nisparol-ix iawed.
r"mnwrdnrinus.nc c.oic dna Policv, nuuGr eo::. � _ A L. l
COMPENSATION INSURANCE
(This section need not becompleod ifsbc mmm i, Ioro«hudrNdollas SIM
or less.)
I candy that in the performance ofthe work for which this permil is issued, l shall
out employ any person in any manner m as to become subject to the Workerif Compact,
•atlhn laws of California. Dar
Applicant
NOTICE TO APPLICANT: If, after making Nie Cenifcan of Exemption, you should
haome subject m Ne Workers Compensation provisions M the Labor Code. you must
foMwn, comply with such provisions or this permit shall Is, demur revoked.
CONSTRUCTION LENDING AGENCY
1 hereby infirm than them iv a conswcdo. lending agency for she pdo.a of
the work for which this permit is issued (Sm. 3097. Civ, C.)
Lenders Name
I<Mcr's Address
I certify that 1 have read this application and awe But the abaw infocmasion is
tet. I agree to comply with ell city and county odassims and ante laws relining an
building comm minon, and hereby aurhode representatives of this city to cover upon the
ehova- m ummil phpnry f« inspection purpoaes.
(We) agree m use. indemnify and kap harmless the City of Cupmino agalml
liabilux,i.judgmems, remitted esprnses which may in say way acme against seidpity
in mnu9uenee of the Br'amir, of Nis pemil, I
' PPIJCANT UNIAiRSTAND\AND.juII.l. COhkPLY pill ALLNOt•�POINT
Will the applicant or form b
defined by the Cupertino Munici
Cole, Section 2553210?
❑Yrs ON.
441 handle haaA.- mescal Re -roofs
9.12, and the RNN,nd safety Type of Roof
W II eo applicant or future building occupant uta equipment of device[ which
e lowd—Adakhua air conomiruno as defined by the Bay Area AU Quality Management
mics?
❑Yes ❑No
y 1 have rtes flat hvmdous matcia , scquimmanss under Chapter 6 101
tar Cali-
Icm fay Cade. Secti s 2550.5. 255. 255)6.1 mem if shfi
Will dms olnu slyhevc re ton, it is ml ansibiliry ro nm if the pant
of the q ma wNc rest m I p a rfcf� a t :ci yN
agent
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
u stands a wi co ly with all non p int ource regulations.
1 rn
i nature of Applicant Da V
OFFICE
All roof coverings to be Class "B" or better