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00030047BUILDING DIVISION PERMIT BUILDINGADDRESS: s ° Baa F y i LICENSED CONTRACTOR'S DECLARATION OZ = 1 hereby affirm that 1. li<ansad un,r provisions of Chapter 9 (co sing with Stttioe7000)nfpIV 0 3 slmsu ofN0 BussdProfessioriC Wm so Is �2U in full to.. and eRcm.'v Lianre Gl% seg 3 a y Da¢ Convector C FS C gARCHITECT'S DECLARATION VLV 1 understand my plvru shall beused m public reemds �'!Sy MO Llceosed Pmfnoionah OWNER -BUILDER DECLARATION z 1 hereby aRnn Nat 1 am exempt from Ne Contractor's License law for the S ❑ following reams. (Station 7031.5. Business and Professions Code: Any City or County T $ which "cions It permit to construct, Wer, improve,man demolish, or repair y increases Prim to its iuumcq than recisions the applicant for such Pemdt to file a signed.Iecam, that he is licensed pursuant to the provisions of the Connotations License law (Chapter 9 (commencing with Section 7000) of Divialm 3 of the Business W Professions Code) or that he is eeempt Nnefrbm W the buis for the alleged exemption. Any violation of Section 7031.5 by any applicenl for a Penna subjects the applicant to a civil Penalty of not mote Nan five hundred doll. (3500). I, as owner of Ne progny,mmy employees with wageam their sole comPemvuon, will dotheatims Cothe sue ContrsnmintWed Law Its to Its Buvinem W arty whom Code: The Cos therw's License law dm Ila & hi to lf owner of his o n who buil, or improve t ..ch , W who dam math work himself or through his on however the provided Net such imams wild w thin not inrendad m Wison, for We. 14 however, drc buildingorimprovrmmt sold dayicaneyearofcomotforFor- 1. the r- owmr-Wilda will Mae the burden of proving shut he day eta Wild or improve for pm - 1 of bow ). ❑ I, construct owner of the property, .B e um any confessing with :) Theed chvuums i. inLatheproject(Sec.7014,wner of all Professions Code:) The Conlranom, and cense law docs an apply w ts owner of t rognY wbo hills rs improvm thereon, W who se La .for such projects with acontraclor(v) IicenvM pursuanuu Ne ConuacnaJs License Law. ❑ 1 am exempt uMer Sec. . B & P C for Nis neamn Owner Dare WORKER'S COMPENSATION DECLARATION 1 hereby aRrm under penalty of perjury one of the following daluavons: ❑ I have BILI will meinuin aCenificam ofCmnmt to self -insure for Workers Corsi sation, ax provided for by Section 3700 of the Labor Code, for the perf r mune of the ww r which this Person is issued. have and will mainmio Workds Campensuian Insurance, as squired by Section 3700 of on Lindon Code, for the Performance of the work for which Nis permit is issued. My Worker'r� ��pJ�9p3p�Ii 1p ate curia and Policy /1 (�' Gorier. /a,/g//�//ZiI, Policy No.//g.V�V1O CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This rali.no i net becomplued Wide Permit is fmone hundreddoll.(3100) m Tau.) I Certify that in the performance of the work for which this Permit is issued, I shag not employ any Peron in any manner' w as to become b,.,. the, Workers' Comgn- W on laws of California. Dam _ Applicant NOTICE TO APPLICANT: If, after making but Certificate of Exemption: you should Itinerate subject to the Workers Compensation'asomons of the Labor Code. you at forthwith comply,wirh math provisions or this pumit shall be domed revoked. CONSTRUCTION LENDING AGENCY 0 I hffim ereby er that there is a conaWCtion ion ing agency for the perforove rm, of z 2 Ntons ank for which this Permit is ismed (Sm. 311 Civ. C.) Fy Lender's Name r` > Landers Addresi [� E I ce;ufy Nm 1 have read Nis application W wan that the above iNnmution is 4Correa. I agree to comply with all city and County ordinances W state laws relating Ia U Q building construction, and hereby Carbonize rcpre ounvm of this city to enter upon the above-mentioned property for inspection pur uses. iz E., (We) agree to ave, in,mnify and kap harmlms the City of Cupertino against C V Iiabdox,,judgmenb, mss all expenses which may in my way mcmeagainn said City >. W lin mrsuequcoce of the gm 'ng of Nis Permll. Fi APPLICANT UNDERS 'ANDWI LIMPLY WITH ALL NON -POINT V 7 SOURCE REGULA Slgnedureof Applicanl/Ga <m Dm: HAZ�\R SMAT' IALS DISCLOSURE Will the applicant or future Wilding occupant store or handle hazardous marerial m ,fin, by Ne CYPeNno Mmiceip CWc, Chapmt 9.12, W Ne Anel, W Salny Cade, Section 255321)1 p Yes Will the applicml m future Wilding occupml use eciuiperam m,vims which emit hazardous sir contmninm efsnad by the Bay Arca Au Quality ManagementDouri,1 Q Y<s No I have read the hearri meteriala Ie9uirements under Chapin 6.95 of the Car - forms Heslth & Safety C Sections Z505. 25533 and 25534. I contained that if the WildingdesamucroserrdY vetsen., thnit is mY respomibiliryronaifY occupant of Ure reuuuemenu which n h nen orioarsgsamrce of s Cmificete ofAttumticv. -t jO 'CBIq�O�R Ii 'F©RI A I +O PERMITNO. dl/Zt 661455t-lwer�, rte. DD ro b {z{5'///, SANITARY NO. APPLICAT /' V [ NIC CO', l�l,�� /)/a1ior� o BI-rLD76 FfaM1ijI'll 5/0 Sq. FL Floor Area Job Description 10 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 aggvee to remove all new materials for inspection.. Applicant understa sand will comply with all non point source regulations. Signalul plicant Date All roof coverines to be Class "B" or better OFFICE