00050002 (2)CITY OF CUPERTINO • R IN 5 'Mf1 I L PERMIT No. -
:nUILmNCDIVISION PERMIT `.`' %' 00 / 000
BUIIIIyyyING D RPS f
/��(.}./�_ is• �i/fJ]I SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S A F.'' �/NI/_,V
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RCHITHCUENGINEER '8 ❑ 4 I ¢P,'RMIT,I.
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.LICENSED CONTRACTOR'S DECLARATION
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Job Deseripdon '
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I hereby a m that I am licensed under provisions o(L spur 9 (comes rowing
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with Section 7000) of Division 3 ofthe Busies and Prof asioi Cillo, and m is
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1 understand my plans mail as public .,
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RATI frDECLAATION - ;
1 hereby a/liw N t 1 exempt empr from he Commences License, Law frothe
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Ofollowing
notion. (Section 7031 .5, Business art Professions Code Any city u wanly
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Sq- [�[, IDDr ACCs .
Valuation
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which req res a Permit to consuract, alar, improve, demoliN repo any awcture
s ra,dco mature, theapphcam for such pemdtl file signed mtement
prior to dwan
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d pumano the provisions of l e Contractors License Law (C7upur9
Nn he is licenusu
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(commencing with Section 7000)of Diviiam3'.fthe Bottom. and Professions Cede)m
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Occupancy Type
Out he is exempt therefrom art the besis for Ne alleged exemption. Any violation a
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Seedon 7031.5 by any applicant fora permit subjects the applicant ... ivil penalty o!
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of mom then five hundrt4 dollen (5500). /
p I, as Owner ofthc property, or my employee¢ with wages as their sole compevadon,
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R quired Inspections r
will de Newark, and the structure is not mended or offered for sale (Ser. 7(114, Buiiuu
and Pmfenkrus Coda: The Conwcror's Littnee law door not apply to son owner of
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property who builds cr improves thereon. nal who does such work himself or through
his own employes, provided that such improvements sen not intended m offered for
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side: If, however, the building or improvement it wild withiumm yen Ofcompletien, the
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ner-Wilder will have the burden of proving that he did not build or improve for pur-
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you of sale.). T.
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. 1. u owner of the property, em exclusively convecting with licensed contractors to
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conswct the project (Sec, 704q Business end Rofesdona CO10 The Co..[.'. Li-'
cense Law doss not apply to an owner of property who builds or improves dmrcon, andwho
mormacts for such ptojmts with aconwmons) licensed punuanuo the COmnetes.
License t Law. _ ^A '
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Ism exempt under Sec, .B&PCforthisrcsson
Owner " Data
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t WORKER'S COMPENSATION DECLARATION -
1 hcrehy atfirm under penalty ofperjury rose of the following declwtioia:
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I have art will nainidn a Certificate of Consent ulf-insu , for Worker's Compen-
ation, as provided for by Secden 3700 of the Labor Code, for Ne performance of Ne
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or w
which this pewit is issued
have and will nttinuin Worker's Compensation Insunncn, m required by Section
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J700of Ne Libm Code, for the performanceO chin work forwhich this pewit is issued.
my Worker$^—C canis end Pelle n
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Crainne ` ] .OM1 ari/1 Policy NbY
CERTBTC INPROM WOR S'
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COMPENSATION INSURANCE
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(This ucrinn need her be comPl<rcdifthe permit is talon¢ huMmd dollars (SIM)
or less.)
Iceni(Y llulin the perfawanttdfthewmkforwhich thiapewit is iieved.l shill
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notcmploYa.ypaao in manner soa ve `uh'alZeWorkerr'COmpum-
antion lawso e' te.D
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aNOTICE TO APPLICA : IL ar making this CWTicl a of Exemption. You should
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become wbjed to the Winker a Compensation provisions or die Labor Code; In ..in
forthwith comply with such provisions or this pewll shall be domed revoked.
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CONSTRUCTION LENDING AGENCY
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(hereby arm thin Nereis a comstmetion lending agency for the perfomuntt of
Ne work for which this pewit is timed (Sec. 3097, Civ. C.)
Lenders Name
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Landers Address
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I cartlfy thou I he. reed this application and ¢Iia that the ahs. information Is
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correct. I agree to comply with all city and county ordinances and sure laws relating to
hrriu entativesOm f this city enter upon Ne
building concdon, and hereby ammpro
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atiova•memiswoned property to, inspection purposes.
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(We) agree to aave, indemnify and keep hawlew the City of Cupertino against
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01,'habilitiea,judgments,mods
rot expenses which may in my way same against said City
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m cnomgtimm of a granting of this pewit:
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APPL .ANTD ERSa'ANDS AND WILIICOMPLY WITH ALL NON POINT
S( IF tEG CATIONS ON
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reof Applicam"co m,law Once
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HAZARDOUSMATERIAIS DISCLOSURE
Re -roofs , - ..
7i/QEly1 C �/j
Type of Roof J�
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Will dramplicent our mina baiIdi meant ¢tort our handle hanatot, reaterial
as defined by the Cupertino Munici Oda Chapter 9.12, sed the Health and Sdety
Com, Section 2ss32(an
❑Yes .:,.
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Will the future gatempentr,eeamiPmenirrdevineswhich
emishazallous w contaminants a fined by the Bay Area Air Quality Management
All roofs shall be inspected prior to any roofing, material being'
installed. If aYoof is installed without first obtaining an inspection
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❑Yea No
I a ree to remove all, new materials -for inspection.,. Applicant
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un ers Ods and will'comply with all non point source regulations. ,
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Ihavrcadthe azerdouetvsrialemquimmmauMerChapa6.9SofthcGli-
-forma Heal Safer e, Seedoni 25505, 25533 and 25531. I understand that if the
hue ingdoo¢ Ica nil evcaunem,thmit is my usponsibilitymnmify the- upmit
of see IS ich SI O(a Cenifi fact ercv.•.1
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ignature Applicant Date
O n rar utllon a D u
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All roof coverings to be Class "B" or better
OFFICE