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v utiu:uwc DIVISION PERMIT CONTRACTOR INFORMATION:
BUD/OD to
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cWN;"Ma' /w SANITARY NO. APPLICAT
IONSUBMITTAL DA
CONTROL#GIGJNIC
PIIDNLhis V .25, Well 9//070 TI
rCHITECT/ENGINEER �G5D1.a9� �'/�� RULDING I'ERhfIT INFO
LICENSED CONTRACTOR'S DECLARATION
I hereby amen that I am licensed under provisions of Chapter 9
withSection ]000) of D oy 3Ne Busixss vnfe�Co` , an
in ran r«a W efieat. �S n � it
1 understand my plans of WI be used as public mcards
Licensed Professional
OWNEon e,uo.DER DECLARATION
I bra a(Bmt Net 11. exempt from the Contras Co License Low Co the
following reams. (Section 703 L5. Business and Professions derona Cede: Any cry a «unry
which requires n permit ml the ¢Iter, improv[, h Factor t ore a sig ed swcwe
priest toits issuance,also requires pr visions f for such Factor mfilesaLaw(sukment
Out in licensed Punta.. to theprovisions 3 dihe CB.Cieo/s Licence Iew(C Code) Or (Command,aisra with Section 100#) of Division J of al B ed exaand Prefesone. M iom Colo)of
Nat he is eamq Nn apph teed the burs for the subjects
rho exemption. Any violation of
not room
them by anydred drat fa a permit mbjecu Ju applicant to r civil #¢redly of
of rswu Nnn five hundred dollen y ompi.
wi Lu eworof Ne pro party. r myempNyar wiNwaBeau Ncir«Ic«mpenuiess
will doth¢work, and the structure
is Ccorisnmintended, Law rell dolor aale(Sec.toaa,..a, of
and it, who
Code: The Contac rem Llanse law does not apply to if owner of
property who Wilde or improves , such i and who don n, O wak deed or w through
his awn oweveraa, provided r i such improvements aro out intended an offered for
galea If. it however Wildingur en of po in isCold within one Wild ri«mple far dre
owar-Wilder will have Nc burden of Proving Nat be dM n« Wild or imprpvc for Pur.
0 1 of sale.).
C 1, u t the
of the property, .l ounam vdy contracting with he Ccontnnon to
on. La Ne project IS.ppl, o an Business and Row1ho Wilds
Code)im sr. Conuanom. and
law dos r such hr je an owns of property wed Wilds or ant to Out
Norton, cad
who contracts for each poj«ta with econtraetor(8licenaed pursuant Ne CanuedoYa
License Lew.
1 em camp. under Sec. . B k P C for this won
OwnerDau
WORKERS COMPENSATION DECLARATION
1 herby affirm under penally of perjury one of the following dectawiau:
I I hav<ard will maiouin a Cenibcateo(Com«t to relf�insure fa WorkefsCompen-
es provided for by Section 3]00 of Ne Labor Code, for Ibe perfomu«e of the
VYY,, which thin permit is issued
[¢`(have and will maintain Workers Compensation Insurance, as rafrood by Section
370oof Nelabor Corn, for die performance of the work for which Nis permit is ismed.
My Wurker' Up��W�. rand Policy nytpbr j5p
C m'er. X11 f'f f f3 }_1L1�11�_e Policy N.: h 4 n DJ V'
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
(This secur,.mad MttrcompluW i(Jra perom. is turn« hundred ddlan(51w)
Or lass.)
I certify that in the peRormarcc of the work for which thispemm is issued, I shall
not employ any Perin in any manner m as in become nbj«uo the Waken' Comperr
ration Laws of Calif.... Dau
Applicant
NOTICE TO APPLICAM': If, after melting Nis Certificate of Exemption, you should
necrotic subject to the Workers Compensation provisium of the Labor Code, you must
foMwith comply with sucM1 provisions or this p rod, shell W deemed revoked.
CONSTRUCTION LENDING AGENCY
Q kfor whaRmi Fa the`a isacansttec. 3M.Cing agency fated perfamunceo!
•z 2 the coat for which this permit is issued (g«. 309], Civ. C.)
Eco Leaders Name
} lenders Address
fresI Certify that I have read this npplicalion and awe that the above irdomuuon Is
C6 A correct. l agree to comply with all city am county ordinances and eta laws relating to
z building conatNciton, and hereby aurhomon representatives of this city to enter upon the
U 0 above-memicrod Property for inspection Purposes.
W F (We) agree to cave, indemnify and kap harmless Ne City of Cupertino against
0 (,) lubiliti<s,judgmcnu. costs and expenses which may in any way accmeagainu mid City
} fa: in cansega«e of be gran Ing of this permit.
I^ �" APPLICANT UNDER: NUSANDWILIjjj���f��MPLY W1 I H ALL NON -POINT
V z SOURCE RF.GUI�TIt,
Signature of Applicmt?Co c Dau (/
H . US MATERIALS DISCLOSURE
Will the applicant or future Wilding occultismpore or handle Date
material
as defined by he Cupertino Mal Codc. Ch NO 9.11, and the HedN end SafetyCode. Section 8533rd?
(]Yrs
Will Ne epplicam or future Wilding account use equipment or devices which
emit hawdous aft conumirunts as defined by the Be, Arta Air Quality Mamgemcnl
District?
fto ❑Yee �T
I havereed the hag uv mnedds requimmenu under CWpur 6.95 of the Cali-
fomu Health & S ry . Sodom 25505, 8533 «d 155.36. I understand than if tic
building dare ndc haviceurunl Ne}Y+� my usponsibiliry, m notify the«cupsin
ofthe muubemenr unbe m: missuanceofaCaofieye ofOCcmay.
Job Description
��i�I9�� wq�ev fugf��
:OU
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
understa s and will comply with all non point spurce e ulations.
�� ��
Signature of ant Date
OFFICE
All roof coverings to be Class "B" or better