00040079L'RTINO
PERMIT
p H i LICENSED CONTRACTOR'S DECLARATION
J L G 1 hereby aRrm that 1 sum licemed under pawitiom of Chapter 9 (communities
- 4 to with Secdm1000)afDivisim3ofthe Buvmas"R feaniau Cade andmyliamcis
Sal S a infullfmaand eIf "
O i O Ulmae Chas it N
i 3 a h DateConuacmr
u. OARCHITECTS DECI-ARA' ION
I undem.ndmY ,War shall N used u public meads
ao E. Ucmred Profcanioml
= a, OWNER-11MDER DECLARATION
I- Z a 1 hereby a?am Nn 1 un exempt tram be Communes Licmm law for the
s o following reams. (Seeim'ro31.5. Buchman and Preassiau Code: Any city or county
i
3 m which mcf.i s • pemdt w ca ncou", alter, im nova, demolish, or repair any rNYc are
prior to its issuance, alw recover the applicant for such sem, to file • signed statement
but he is licensed pursuant to the provisions of the Conowtorr Usme, law (Clupler9
(commencing with Section 7").f Division 3 of Ne Business and Rofcnsionr Code) or
Nat he it exempt therefrom and the heir, for the alleged exemption. Any violation of
Section 1031.5 by any applicut fa a permit mbjec. the applicant 19 a civil penal
cwt more Jun five hundred dollen (5500).
❑ I,. own. of be progeny, or my employers with wages u chair rale roe nude,
will du be work, and the amacluse is net intended a offered far sale(Sec. 1014.9u ems
and Rofemem Code: The Comeanor'5 Liamer law does asst apply to an owner of
property who builds or improve therms, and who dors inch work himself a through
his own em,layms, pravided that such impovenann art nor intended or offered one
vale. If. hina., the building or improvement in sold within me year of completion, the
mater,taidde, will heve tM bathes of proving that he did not build or improve for pur-
pow of mc.).
I. as owner of the property, am exclutively cmnwtiog with licensed commas to
construct Ne pmjem (Sec. 70414. Busimrs real protectors CodeO T1s Connector's U-
na Law does ml apply no an owner of property who Wilds or initiatives thereon, and
who contracts for each ptojecu with aemmctWs) licensed punuw no be Convectors
Lacers. law.
\ O lamexamptunder Sec. .BAPCforthirwon
Owner Dace
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury me of be following declamriam:
I have and will maintain a Certificate ofConsant no m6insu l for Worker's Compere
o mai
as provided for by Section 3100 of be labor Code, for the teff.. of the
mat fa which Nis pcmJt is issued.
have and will maimm Waters Compensation Imusem , u mcb it l by Section
7 lithe IaNr Code. for the performana of the wwt for which Nis parmit is intend.
My Worteri Compensation In.stro me canis and policy number art:
Camee Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This scrim need no N comPleedifthe permit is formehurdred calla. SIN)
or Ins.)
I certify Nat in be psdonnaaae of be work for which Niapemdt is issued. ) hall
net employ my peon in my manner at as to become subject to the WarknraCompere
maim laws of California. Wte
Applicator
NOGCE lU APPLICANT. If, after salons Nit Cenifiate of Exemption, you mWIJ
become aobject to the Wadeh Compensation pmvisions of Ne labor Cade, yore must
fmhwith comply with unit pmvisions or his pcnnh shell te deemed revoked.
CONSTRUCTION 1 -ENDING AGENCY
Q Ihereby affirm the Nem is construction lending agency for dte performuae of
Z Ne mat for which this permit in issued (Sec. 3091, Civ. C.)
(.., Undrrs Name
ye > Iender,AdAman
tz]1 certify Net i have read Nice applicaim and chat at Ne above information is
L z enact. l agree to comply with all city and coney on immen and aum laws altering to
Z) Z Wildingc.,.do.. and hereby authorise noptesumad,e of Nis city as enter upon the
:.i shavomentia ted porosity for inspection purposes.
(We) .,me no wive, indemnify and lace, hermlus the City of Cupertino against
U hbiliues,.xi inems,cos.and ca ..... hich may in my way ac me against said City
>., lay) in emsetuema of the granting of Nis permit.
F_ S APPLICANT UNDERSFA NDSAN) WILL COMPLY WI'I I ALL NON.WINT
U Z SOUR-REGUI.ATI NS.
Si,.irl'ApplaantlComnct Dau
HAZARDOUS MATERIALS DISCLOSURE
Will the aWllcam or future pudding occupant small, handle ha..rdous m omial
as defined by the Cupertino Municipal Code, Chapter 9.12, vd she Health and Safety
Code, Smtim S532(a)1
,Yen ON.
Will the applicant or future Nilding occupmt use equipment or davices which
mit haradoua ah cmuuniun. a defined by the Bay Aro. An Quality Management
'no
❑Yes Fl No
'; I have noel Nu
e heaunder
dout materials minimum. Chapter 6.95 of the Cali-
uru Health Se Safety Code, Sections 25505. 8533 and ZW3 . 1 and.sand that if Joe
NilQ�ttgd. onot cu rly oliveetee.m, bat iusmy 2sInunsibilitymnreify the acupmt
9f thlipyuri men. this skbe met Inner ler issuance ofa Cani¢cgaof OccuMnc'y.
CONTRACTOR INFORMATION: Oh V r ' oo
Alk Os," 4k&-/•Ae 4 Geo ins SANITARYNO. APPLI
14V
rjo ,Raa�aw V,w Bid 99
phVartu+L ur9u Ll. N"
Job Description
Rp" �e sN
Sq -Ft. -Floor Area
3�a
sir
Re -roofs
Type of Roof
APR 1 2 2000
&-;1 O
5) -
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 Applicant
OFFICE
All roof
Date
to be Class 'B" or better