00090092BUILDING DIVISION PERMIT
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Z 0 LICENSED CONTRACTOR'S DECLARATION
1 beaby affirm Net 1 un licensed seeder provisions of Chapter 9 (commencing
u01 with Sec4on 9000)afDivision 3 oft., Business eMPrywi_ one Cada. eMmy license
y f in full force ate effect If,._�'+]
vA
erect l.lces, Class Li, M
3 a y Dne Conuecmr_L
F. O ARCHDECCS DEC ' O
I undernssd my plans shell W used as publi
a�
O Llaensei professional
OWNER.B=ER DE 1
< 1 hereby affirm Nn I am exempt from Ne Contracw icons r^ the
$ O following tenon. (Sortie. 7031.5. Business and profeuioa Cade: Any a y my
6 3 m which oxione. a permit W commum. alar, improve, demolish, or repair any rwctue
prim W its ic..., also require, the Wheat for such permit W file a signed swement
Met M is licensed pursuant to Ne provisions of the Conuacones Liana law (Chep.9
(commcmng with Section 7").f Division 3 of Ne Business and I'mfeuloas Code) m
Met he is eumpt therefrom send the basis for Ne elkgd exemption. Any violation of
Section 7031.5 by any applicant for a pemtit subjects the applicant to. civil Madly of
of more than five hundred dollars ($500).
1, ore owner of the propeny,'ar my employec. with wage u their sole compensation,
will do to work. ate thertmcture issue, instead reoffered for We ecce, 7044. Business
and professions Code: The Contractors License low does nor apply to an owner of
pmper y who Wilds or improvas thereon. and who doe. such work himself or through
his own employees. Movidd ret such impronmau art was intended or offend for
We. If, how., Me building or improvement is sold within one yearof completion, rhe
rwncr-builder will have the budlen of proving diet In did nor Wild or im now for pu-
poseafaela).
❑ 1, as owner of de property, am excluslwly cono-acung with licensed contractors; W
ansmet Ne project (Sec. 1044, Business ate Fromsu e. Code:) The Convenors Li-
catse Lew owns.. apply 1. an owner of property who dtilds or improvas thereon, end
whocontracts for such projects wither counselors) licensed pursuant to Ne Count
Lia a law.
❑tun can 5 .B R PSC ffoor mi, reason
'I rownu Das LH.f(1�3L
WORKER'S COMPENSATI ON
I hereby etflrm under penury of perjury own a fellaving declwiom:
sstion, as provided fa by Section 3100 of the Labor Code, for the perfomuae of the
woh fee which Ni. pe rn t is Issued.
❑ 1 hart ate will muntein Writer. Compenasuon Insurance, ss equird by Section
3100of the labor Cade, forte work for which this permit is issued.
My Waiter. Compensation Insurance carrier and policy number as:
Carver: policy No.:
CERoRCATE OF EXEAWUON FROM WORKERS'
COMPENSATION INSURANCE
(This ucn. race. becomplund ifNe peanut is foruoehurrAddollaw (SIM)
or lac)
I certify Met in the performance of the work for which this pesmil is issued, I shall
tun employ any person in any menar so as to become subject to the Waken' Course,
tion taws of CaliI.iw Dau
App sent
73
NOTICE TO APPLICANT: IL slur malting Nis Cenirs m of Exempdon, ym should
beamith cop t to the Waters Canp or this provisions of tde lata Cade, . man
foMwiN comply with such provisions or this permit shell be dermal mokd.
CONSIRUMON LENDING AGENCY
I herby affirm that Wert iso concoction lending agency, for Ne pufanunee of
z .+ the work for which Nis permit is issod rice. 3091. Cil Q
lander. Name
a 7 lander. Address
{a 1 certify, rhe I its. read this application and awe Nat the above information is
CIOz correct.I spree W comply with all city next county oNinwua ate rare few, relWng m
V O Wilding oorevucumt.and hereby.uthorine repseedalNes of this city W enter upon the
above-mentioned property for iapation purposes.
GL For (We) .gree W sawn, indemnify and kap bumlers the City of Cuperino spinet
0 C.) liabilitin,jtegmau,cosuand expanses which may in any way.caueyuast said City
in omwespumen of rhe granng o
tif thin permit.
>. a ANPR2LjC.%kbTUNDERSrANDSAND LI.COMPLYWITHAILNON-PRINT
o A uam/Conwnm Dere
HATARDOUS'MA SURE
Will thespplicant or future Wilding c.peal sae a handle hazudoas material
as defined by rhe Cupertino
acipal Cade. Chapter 9.12. ted Ne Health and Safety
Cade, Senior 25532(.)?
❑Yes No
Will t e applicant or future building occupant use equiprrcot or devices which
emit Wasted.. e,4 emosso nests ss de0ud by the Bey Ares An Quality Manegnm tel
District?
oven No
1 have read to herardoun material, oxparnments undo Chapwb 93 of the cali-
fania Health A Safety Code. Sections 25,WM533 rte 25534. 1 understand that if the
PERMIT NO.
NIC CONTROL#
725
Job Description
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Required Inspections
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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. Applicant
unclerstands and will comply with all non point source regulations.
Signature of Applicant Date
OFFICE
All roof coverings to be Class 'B" or better