9040053CITY OF CUPERI NO
BUILDING DIVISION PERMIT
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WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificate of Consent to self -insure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
0 I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carver. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ffhis section need not be completed if the permit is forone hundred dollars ($100)
or less.)
1 certify that in the performance of thew k for which this rmit is issued, 1 shall not
empfoy any person in any m
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of
Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous material
defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
ode, Section 25532(a)?
0 Yes �!m
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
0 Yes :11
1 have read the bamrdous materials requirements under Chapter 6.95 of the Califor-
nia Health &Safely Code, Sections 25505, 533 and 25534. 1 understand that ifthe building
docs not cum
nt!y� have a Imam, tha u ' my responsibility tqAtotify the oceu t ofib
e
wmuimmcnts wfifch must be met ott�r issuance o(a CcrtiFEate of Occuoartfy.
or authorized amni
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Issued by: Date t
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.
Signature of Applicant Date
All roof coverings to be Class "tY " or better