00040164IIf VC I:UrLKI LINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: OQO O I
LICENSED CONTRACTOR'S DECLARATION
I Formby affirm Nu 1 sm licensed under provisions of Chapter 9 (comtaoeing
wish Section 7")ofDivjjscan 3 Ohn Bminres and Prof 'ora ode, and my license is
in full face and affect I '2
License a Lic.
Dene Convector
ARCHITECTS DECLARATION
1 underetend my plan shall W used as public rtmrds
Berme Pmfauional
OWNER -BUDDER DECLARATION
1 hereby affirm that 1 am exempt from the Contracmh License Law for the
following reason. (Section 703 1.5, Business and Pref nciom Code: Any city or county
which rtquines a permit m eausb ct, al -a improve, demolish, or npam any auucmn
prig m hs issuanee. Ms. twuiron the applicant for such permit 10 file a signed autcmrm
that he is licensed ponuent m the provisions of the Co..same. Licence Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Profession Cade) ne
that he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
Section 70313 by any appBaut fora pamdt subjes" thea in—' in a civil penalty of
not mon then five hundreddollen 01.
(350
I'as owner of oo peoper y, or my employees with wages n their mit compensation,
will dethenark, endo: The Contractor's Lure La.desfor a(SaJ0a4.wnera
and property
whom Code: imp overoLioense Ido does tea apply s lf owner of
property who build. or improver thereon, and who der such work d d in a through
his own employees. Provided Nm such improvement tie not intended ee oRems. for
sale.ILhowrser,the Wildingor oen a gown issold ,did nt Wild
rr improve
for the
eof Weer will have the Wrden of proving that W did not build or improve fa pa-
posse
I. as owner of the property am exclu
sivelynd cannsdns with Ikrmed onnuamon i-
amwes the project (Secp,ly 1. n owner of
Profession&or i The Connector's rad
come Lew docs nos apply jc an owner of property coca builds or improves thereon, and
who con La(m such projam
u with acontrecr(s) licemd pursuanmuse Contracmta
0 1 a Law.
1 am exempt under Sec. . B ,II P C for this noon
Owner Dan
WORKERS COMPENSATION DECLARATION
I herby efErm ander penalty of perjury one of the following declaration:
ho 1 have andwill mainsin a Certificateof Consent m self-lnsun fa WorkefaCompen-
tice. as provided for by Scomin 37W of the UWr Cede, for the performance of the
k for which this permit is issued.
I have rad will maintain Worker's Compensation Invnance, u required by Section
IXI of the IAWr Coca far the performance of the work for which this permit is issued,
My W t qy m
ranee carrier and Policy IZnGi O1 ue
sl
Cenie�( YI Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
roti. xatirm oeednor Lecomplen.d ifthe pcmtit is fmatehandood dellen (SIM)
re lesn.)
1 Gasify that in she performamc of the work for which mi. permit is issue0.l shall
ea employ any person in any molest so as to become subject to the Workers• Canpen-
vemb Laws of California. Den
Applicant
NOTICE TO APPLICANT: If. eller making this Cenifeaa of Exemption, yon should
become subject to the Wool Compensation provisions of the Lauber Code, you most
fmshwith comply wish such pranducns or his permit shall be deemed revoke.
CONSTRUCTION LENDING AGENCY
1 hereby offitm the then is a combination lending agency forthe p<Rosmamr of
the work for which this permit is isad (Sec. 3097. Civ. C )
LavalAddress
1 certify but 1 have rad blit, apphcmion and sun. that tW above information is
cornet. I agree to Comply with all city and county mdlNnces and aura laws relating to
building conswction, and hereby authorise rtpreunW ives of this city to enter upon the
above-memiawd property fa impectian purposes.
(We) agree or rave, indemnify and kap harmless the City of Cupertino i gairut
liahilmes, judgments, cost and expresses which may in any way accrue against said City
in conuganor of she granting of this permit.
APPLICAN-1UNDERSTANDS AND WI I.I. COMPLY WITH ALL NONtPOINTI
SITU RCI: REGULA'1'IO
G V
Sigmmcof Applies Convexo D.
RIlO S MATERIAIS DISCLOSDRG
Will dat applies m Wilding occupom non or handle harandous mattrial
as defined by the Cupertino Municipal Code, Chapter 9. 12. and the Heel and Safety
Code, Section 25532(11)7
❑ Yes
Will that applicant or form Wilding notation ase equipment or devices which
mit harardous an contaminant as defined by the Bay Arta Ab Quality Management
1District?
❑Yes QNo
1 have rad the hacandoeulls mmensis rtqu rament under Chapter 6.95 of the Cali-
fmnu Health It Safety Code, Sections 255115. M533 end 25534.1 understand that if tW
building does net currently have a temnl don it is my responsibility m ossify the ot't Mot
of the es,inmena h must W met prim m issuane of uof the h must met prim m of a Cmif�����
owner P-1 dagem I eau
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Bial allo��t &e
j����D�c1, GA 9/5�/s•
LSoo) 293 ZD�2
iN
Job Description �alz�
iP��/��e Did//off ��r1�` T
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 agree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of A bean, Date
All roof coverings to be Class "B" or better
OFFICE