00050075-' - BUILDING DIVISION PL'(q,
BUILDINGADDRESS:
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Z O N Z LICENSED CONTRACTOR'S DECLARATION
O Z _
thereby sffmm Net 1 am licrnsd oder provitione of Chapnr 9 (commencing
F=C with Section 70ro)ofDivision3ofthe Busimssmdp fe ons Code.admylicen"is
< y i in lull force ad affect -
5 in 004 U Litems. Class - t ' Lie 0
Can m
O ARCHITECTS DECLARATION ,
1 undenreM my pfar rhalf be usr4 a public ancrods -
a License!PmBumaW
uw1 - OWNER-BUR.DER DECLARATION .
I bertby M. that I an exempt from the Comracmrs License law fm the
S E ❑ following room (Semon 7031.5, Buitneu ad Profacimt Cade: My city a early
i.3 2 which taryirta a parnit m economic, dm, improve, demolish, or repair any atrucmre
prior w its iesuance, alw requires Ne applicant fm auch permiva file A dilads"Wment
rim W is Reamed pursuant mUn provisions coolies Co names License law (Chapta9
(commencingwith Section 70)0)of Division3 of Wa BuumuoriR feuiom Code)m
Uma he is escmpt therefrom end the basis for Ne alleged aemprian. Any violem, of
Section 7031.5 by any.,Iic.t for a p osell subjects Us, applicut In. civil prmlty of
not more Lin five hudad dollen (1500).
1, n owner of Ne progeny, or mY emPloyoer with wages u rheinele maps nudon,
sed do Newod, cod Nemutton itretintended Lion, do(or"l apply 70Ed, Buaineu
ad Preproperty
wh b Cade: The Conoanml Liame law don ml apply ro 1f owner It
his own who builds or improve, t Merton, and who dor such work Mmulf or a mugh
his own cmewc, t e, provided Nn such Improvements ere na intended a offered for
come IL however, rine building or impmveroent is sold within one ymrafwmple for she
wn
pmbuiMm will have the burden of proving Nat W did mol build m improve for pm-
' -pore of cele.), ,.
I, as owner of this, proper, sm eselusively cootr"tin8 wish licensed contractor W
casecall the project (Sec. 7014, Business ad Profnuia s Care:) The Cmlr"ta'a Li-
cense law does not apply to an owner of property who builds or improves thereon, and
who contracts for such pecie,ts with a con riclmfsl licensed punuhnc an the Conmxmrs
lianas law.
❑larrr eaempr oder Sea ,B&P C for this moon
0TwarOwner Da¢
WORKER'S COMPENSATION DECLARATION
I hereby iMms under gamely of perjury more of the fa0owing declantiom:
Cl Iliso adwill nuintaina Certificate of Comanuo aelf-meurefaWorkersCampen-
k
m."provided fw by Section 3700 of she Labor Cdc, fm Ne perfonmoee of the
for which this permit is issued,
1 have and will maintain Workers Compensation Insurance.In raquird by SaaionUgfNe labor Cad, Marine perfwmu�ttofrhe work for which Nit permit is homed.
tier's Compensation Insurance carrier end Palley number tae:
tlin: - Policy No.:
CERTIFICATE OF Pf10N FROM WORKERS'
COMPENSATION INSURANCE
(This .1sma need men be completed if the permit is far oma hudred dollar (1100),
a its".)
I renifY that in the prrfasmme of the work fa which this permit is issued, i shall
nd employ any person in tiny manner so as to become subject o We Workers' Compen-
sation Laws of Cdif rmia. Den,
Applicen
NOTICE TO APPLICANT, If, after making this Certifmare of Hampden, you should
become aubjat to the Warkera Compensation provisions oPUn Labor Ced, you most
Nobb.id, comply with such provisions or this pa nd shall be decreed s.vokd.
CONSTRUCTION LENDING AGENCY
l hereby slBnn Utas there i, a consrmmlom lending egenry forted Nor.. of
z dne work for which IN. permit is loud (Sec, 3097, Ci, CJ
Lenders Name
Lender, Addrt"
d Q correct.
certify Nu 1 have read this it'hI"inn sod sora Wt she above foreman ion is
nen. I agree to comply with all city and county calm...ad ems laws rtlning to
C.i Obuildingcroswcdn..d herebyauthorize representatives ofthi, city m ennrupon the
above-mrneiond property fm inspection paposes.
(We) ,gra an cove, indemnify Nd keep bummers the City of Cupertino .'em"
Q V liabilities. judgments,costs and expenses which may in any way acme against said City.
} W in consultant, of the granting of thi. permit.
0- AP .ICANT UNDF,RVIANDS AND WILL COMPLY WITH ALL NON -POINT
. U RCF, REOUTATIONS.
rgnaturt of ApplcenUConvactor Dan
PERMR NO.
r , SANITARYNO. APPLI=A TONSUBMD7AL
to In eV` a /J
. NN I CONTROLB o...
Job Descri
pt
ion ,
Sq. Ft. Floor Area ' Valuation
ei�
APN Number Occupancy Type
37
Required Inspections
1
HAZARDOUS MATERIALS DISCLOSURE
Will sheepplicem orfutme Wilding ampenr strrrtmhadle haaANoua manrisl, Re -roofs
rs defined by Ne Cupertino Municipal Cade, Chaper 9.13, ad the Healb ord Safety
Cdh, Section 25533007 Type of Roof...
El Yes ❑No
Will the applicant or future Wilding mcupant ire equipment or devic"which All roofs shall be inspected prior to any roofing material being'
7=uilld3
mit It On$ Air e°^W,inann"defined by the Bay Arca AR Qn.liy Management installed. If a roof is installed without first obtaining an inspection
nii7 I agree to -remove all new materials for inspection. Applicant
❑Y<s ❑No, d
W W " m,�Anw, mgm;m ne n d r exp 6„afN �. i- un erstands And,will comply with all non point source regulations.
Hulth & Strictly Care. Sodom 8505,15533 end 25534. I udenmdl Net if Ne;
nL hevcemnam,thnhitmYrtspomibilitymnaifyUteoccupantf the rmust be mer prism rise. ofa CartiOas. ofwnerr ran Signature of Applicant Date ,
All roof coverings to be Class "B” or better
OFFICE