06040167Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
1 certify that in the performance of work for which this permit is issued. 1 shall not
employ any person in any ann r s u c o t� subecl to the Workers'Compensation
Laws of C if 'a.
Applicant
NOTICE T P C • i`a[crimaking this C cats of Exemption, you should
become subject to the Worker's Compensation provi of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Lenders Address
1 certify that 1 have read this application and state that the above infor ljun is
correct 1 agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize rcprescntatives of this city to enter upon the
ahove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue againstsaid City
in consequence of the granting of this
APPLICANT UNDE STANDS AND L COMP Y W TFj�ALL ON -POINT
SOU E GU A �C 6�
Signa
ficatc o(Idccppfry/`� ` Signature of Applicant
authorized
Date
All roof coverings to be Class "B" or better