00040134CUPERTINO FERMI I
qO DIVISION PERMIT CONTRACTOR INFORMATION: ON 40 0
PITONS: [Jr0(S •'' w/ I � ' f W V
Iv
LICENSED CONTRACTOR'S DECLARATION
I hemb, affirm and 1 am licenced under pmvisium of Chap.' 9 (commencing
with Section 7000) ofDivimim 3 ofthe BmiMuantl Profrsion, Cade. W my It.. is
in NII forceandellen.
License Class Li'.0
D to Connector
ARCHITECrS DECLARATION
Iundopt�l4 my plain sf W I be toad u public rccwds
Licaed etaIionss
OW=RD RATION
I hereby of rat Out 1 and exempt from the Contractor's Licause, Law for the
following reason. (Section 7031.5, Business and Profeasions Code: Any city m county
which "comes a permit to cansu n , alter, impmve, demolish, or repdr any atrus.
prim to its issuance, dm requires the applicant fm such permit to file a signed statement
that he is licensed Pursuant to the provisions of the Coan actofa License Law Chapter
(conmmmiag with Section 7000) of Division 3 of the Business and Profession, Code)ne
Oat he is exempt Ihmefmm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
n more Inas five hundred dollars (SW)).
j I,..oflhe p,operty, or my employees with wager.Orcu sole compewdon.
11do the work, and the shuctuta is rot intended or offered For We(So ,1049. [howeu
and Profusions Cade: The Cmdrustor's License Law does nm apply m an owner d
pmpeny who builds or improves thereon, and who does such worts himself or through
his own employees. provided this, such inlpovements tae nal intended or oRemd fm
We, If, however. she budding or improvement u odd within ore ywofeomplation, the
owner Wilder will have the burden of proving Nal las did not build or improve for per -
pm of sale.).
❑ L as owner of she pmprty, an exclusively cio tr.0ng with licened .... to
cmrtnuct the project (So, 7W, But.. and Professions Cade:) The Copra tam's Li-
cense law does not apply to an owner of property w W Wilds or improves thereon, tad
who contracts for such projects with a contractor(s) licensed pursuant to the Comsacmfs
LicenseLaw.
[Ilam exemptun .B&PCf t i reason
Owncr etc
00
WORKER'SCOMPENSA ONDECIARATION
L hereby affirm under pumdry of perjury, ore of the following declaratimu:
❑ I have and will maintain a Cent of Comenuo ulf-insurefrrWonkdaCompen-
sation, as provided for by Section 3100 of the Labor Cndc, for the ptfomuae of the
work for which this permit is issued.
0 1 have and will maintain Workce. Compensation Inwtatee, as nequied by Station
3700of the labor Code, for Je perfonnmee oftnc work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF E%EMMON FROM WORKERS'
COMPENSATION INSURANCE
(This saline n«d nm be completed tithe puri, is far. hundred dellen U$IW)
m los.)
I certify flat in the perform. of the wmk for which this penal, is issued, l shall
nm employ any, person in any mame'so.Ia beeco�b\ct to the workers' Comper-
setinnlawsofCalifomiyBele % J
NOTICE TO APPLICANT': If, after making On certificate til Exempting, you should
becote subject to the Wohds Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit atoll W deerrad revoked.
CONSTRUCTION LENDING AGENCY
1 hemby affirm then Jetta is a construction lending agency for Nee pdorm.tt of
the weak for which this permit is Isueed (Sae. 3091. Civ. C.)
Lardse, Name
Leaden Address
1 certify, Jul I have ead this application and state Jul the above infomwtion Is
wrrtct. I ages to comply with dl city and county odimnes and some laws relating to
building construction. and hereby wdand. representatives of this city to enu, upon the
ahov>memimad pmpny for inspection purposes.
(We) agree to a... indemnify and kap lu m leu tW City of Cupnino agalmt
liabilities, judgments, costs and a.,. which may in any way accmeogalnn said City
in conaequcoce of the granting of this pooh.
APPLICANT UNDERSTANDS AND Wt LI, CUM PLY WIT II ALL. NON.POIN r
SOURCE REGUTATIONS.
Signature of ApplicanJConmctor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or turn. Wilding aaupent amm or handle hand... moarial
u defined by the Catania. Municipal Code. Chapter 9.12. and the H W th and Set
Code. Station 25532(s)1
[I Yes r(No
Will the applicant or fume Wilding occupant tau equipment or devices which
emit hazardous a'r contaminants as defined by the Bay Atex Am Quality Management
District?
C] Yu. o
1 have read the hazardous matartala nequi rments order Chaper 6.95 of the Cali-
fomia Health @ Safety Cade, Sections 25505, 25533 and 25530. I understand that if the
Whaling dote not turns. ly haveaenrnk than. y responsibility to nmifYthe c.pay,
of the ¢Iwiraeeeu which pills. be met ptie/6 y9.. of a Cenilicngof fjeeupamy.
Job Description
NIC
El
�j4b 9� V00H vO1It0Al C 2 PJB QF1 r
umo
Sq. Ft. Floor Area I Valuation O=_
'7773?
O0
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
and nds and will comply wit ll non point source regulations.
4L to Db
nature of AnAicant Date
All roof coverings to be Class "B" or better