00050052 (2)rY OF CUPERTINO
BUILDING DIVISION PERMIT COP
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 an licensed under provisions of Chapter 9 (mmmercing
with Section ]0(t0) ofDivisim 3 of the Busincsa and Profession, Cods, and my liana is
in full force aW effect.
joemeClan ese
D e .(�---- Contra -1
ARCHITECTS DECLARA ION
denra_W mY sM yyetrpu 'c tecada —
Lliscinc�'i mfeaat al %YS�
OWNFto exempt
DECLARATION
1 hereby .(Sato that 11. eBrome from the Commons Co e:A nve Law the
following realm. (Sermon 1031.5, 1. non. and proimprove.
donnish.
Code: Any city . county.
which requite a e,licirrinw b comuucs, alta, Improve, demolish. a repair end Moment
thawtoits iaeuenu,elmtegoina star applicant
of Ito C permittofilea signed Moment
that he is liamed pusuantto Neprovision of the Contractorsnd law(C Cole)
tcommcs exe with hecuoeficul ofDivision3 oft he Businessad Pofeuiom Coaela
But u is 31.5lb therefrom and Uta buil ilea be It sgd sec 1010. AOY noWim
Sutton 2031.5 by any apphcut For a permit mbjecm the applicanuo •civil pe of
no more than five hundmd dollen (5300).
will
Lasowncrof the pro pcny.mmYemployae or
Goole etiov,
will do N<Work,Od the atralure is mnintcnddor offeree ilea Wc(Sec: 201a,Bu� u
and Pmfeuiotn Code: The Cmuacror's License taw doss no apply to an owner o
property who Wilda or improves themoq and who dose such work himself or through
his own employees, provided that such improvements art no intended m offered for
.It. If, however, Ne Wilding in improvement Is aold within me year of oss"Isuon, she
nen W alder will have the Wsden of proving that he did not Wild or improve for pur-
pose of We.).
1, as owner of the propcoy. ares exclusively cor acune with licensed contractors in
...small the project (Ssc, 7W, Burin. and Professions Cede:) The ConlrecnMs U
cense raw dao WE apply to an owns o/ pmpenY w W Wilda or imprava thereon, and
whocantruts for such pojam with a Woursome) licensed ponaunt in Ne Contractors
u«nae Law.
❑ I am eaempmnder Sec. . B & P C for this anon
Ownu Dao
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pantry of perjury one of the following declentimu:
I have and will maintain a Certificate ofComenuo self-imum for Worker's Compete
nation. as pmvided for by Su6on 3000 of the Labor Code, for the perfit.c of the
work for which this permit is issued.
I have sad will mention Workers Compensation Insurance, as required by Section
3700 often Lobar Cab. for the perfismarcc of t e work for which this permit is issue.
�ly Workces Co n'rusaim Insurance tuner aW Policy numbs ere:
Cartier: policy No.:
CERTEFICATE OF F EMFTION FROM WORKERS'
COMPENSATLON INSURANCE
(Mi. vection incl tot be compbnd if Ne permit is for oa hooded dellen (SIW)
m leas.)
1 certify that in the perfantuna of Ne work for which this pemut is iuued.I shall
mi .Nov anv..a in env manner
-11 ro become subject to the WYrkmi Compen-
sS`(DZ TOAPPUCA". IfagRerFreYtlg Nit CeniGcate of Exempuon, you.hould
j subject to rhe Work pr Compensation .if
A.1 of cle Labor Cde, you mutt
fo owith comply with such provisions or This permit shall be dosed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm then there is a comw[dem lending agency forthe perfomunce of
the weak for which this permit is issued (Sec. 3W7. Civ. C.)
Lenders Name
lenders Addnv
I certify this 1 have rued this application sad aloe this the above or.tion is
correct. I egret to comply with all city and county ordinances and au¢ laws refuting to
Wilding conswcuon, and hereby vuthonu Wour tnivn or this city to enter No the
above-mentioned property for inspection puryoaes.
(We) .gree to save. indemnify and kap humlesa the City of Cupertino against
li.bililie ,judgments, loom end e.penser which troy in any way acerae against said City
Innse,in a of the grunting of this general.
AYPLICAN'IUNDERSTANDS AND WELL COMPLY WE In ALI. NfINdY➢N'r
Sig of AppliunUContnnor Dna
HAZARDOUS MATERIALS DISCLOSURE
W ll the applicant or house Willing occupant store in handle haazuams mntenal
as defined by rhe Cupertino Municipal Code. Chapter 9.12, and the HWN and Safety
Cde, Section V532fq'
❑Yea ON.
Will the applicant or future building occupant use equipment or devices which
mit harnd[us tar contaminants as defined by she Bay Area Air Quality Management
Matrler2
[-1 Y.. 0 N
1 have read the lurudaus materials toquiremsnm under Chapter 6,95 of Be Cali -
focus Hcdth & Safety Coda. Secuau 25505. 25533 said Z5N.1 utdcnund than if she
Wildmis coca. currently have n lerwnl. Nat it is in, scamewilshry to naifY rhe occupem
ACr'N V/ EW C.w q f y
Job Description
Ce�PcI� 2t�, �E
5�
Re -roofs
Type of Roof
X o5005a-
N
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