04080022-1BUILDING DIVISION PERMIT
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04080022
PERMIT ISSUE DATE
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 burchy affirm that l am licensed under p ovisions of Chapter 9 (commencing
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wiectio the I'D ?or 3 of Butanes anfj'safcsuumm
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in full fo n ec.L'
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SIGN
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CONTRACTOR: LEE BOLLA SIGNS
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�QcrsunJ my Plum shall be usedasp rtenrds
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Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
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following reason. (Section 703 1.5, Business and Professions Code: Any city or county
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which mutinies; a permit to csmniuct alcor, narrow. demolish, or mpaii any m a"a oat
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prior m its issuance, also requires me applicant for such permit to G',. gtied autemem
Conbaroh License law(Ch apter9
Sq. Ft. Floor Area
that he is licensed pursuant to the provisions of the
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(commencing with Section 7000) of Division 3 of the Business and Profen... CMe)m
that he is attempt tMm(mm and the basis far the ailegcd exemption. Any violation of
Secdoa 7031.5 by any applicant for a permit subjecu the applicant of a civil penahy of
APN Number
not mom than five hundred della. ($500).
I, so owner of the pmpeny, or my employees with wage u their sole compensation,
will do the work end the.wctum is not intended oraff aad rorsale (See. 7014, Business
and Profe>dom Code: The Grammes License Law does nal apply to an owner of
Property who buil N or ire prem s thereon. aM who does such work himself or through his
own employcas. provided that such improvements ere not intended or offered for sale. If,
however. the building or improvement is sold within am year of completion, the owner.
builder will have Ne Widen of graving that he did Wt build or improve for purpose of
sale.).
❑ I, as owner of the property. am uelmively convecting with licensed Contractors to
conswct the project (Sec. 7W. Business and Profesuom Code:) Th. Comeecmr's U.
Cause law drum, not apply m an owner of propeny who builds or improves thereon, and
who contracts for such projects with a convactar(U linnmd pursuant to the Contiactah
License law.
❑ I am ecmq under Sao .B h P C for this reason
Owner Dem
WORKER'S COMPENSATION DECLARATION
1 hereby affairs under penalty of perjury rete of the fallowing duclantiom:
,an and will meimain a Cenificae of Consent m self -alum far Wo,lool Coni
on, . provided for by Section 3700 of that tabor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worked Compensation Insurance. as mquimd by Section
3700 of the Labor Code, (or use performance of the work fmwhich this permit is issued
My Wc/Im ACompensatjpn Imnursnca carrier and Policy number am:
an, be completed if tbe permit isXrronehundred di ($1(1(1)
1 certify, that in the Performance of Ne work for which this perosis in issued, 1 Nall nm
employ any person in any manner an as to become subject to the Workers' Compensation
Required Inspections
PERMITINFO
250
NOTICE TO APPLICANT: If. after making this Cenifcate of Exemption, you should
become subject to Ne Worker 3 Compensation previsions of Be, LiWr Code. you most
Q Z mrthwith comply with such provisions or this Permit %hall be deemed reveled.
Z O CONSTRUCTION LENDING AGENCY
(~ I hereby alarm that dere is a consuuctinr lending agency for the performance of
Rei the work fur which this Permit Is issued (See. ID 7, Civ. C.)
W� Q Undcr's Name
Q z Under'i Address
V Q I Gentry that I have it this application and sum the Ne aWve informed m is
ly E comet I agree to comply with all city and county ordinaruss and auk laws calming to
Q rlJ^ building construction. and hereby auhorimrepresenatives ofthu city m carer UrMn do
W above-memiomeh
for inspection puspmes (\
Ly, py (We) agmdcmnify and keep less the City of Cupertino against
Ird fA liabilitio,Judgend expert hie yin any way accme apinst sand City
fJz In consegucnting of rte, /i
o-4 APPLICAN7�AND�w 'OMPLY WITH ALL N/_--!0FaT _Issued by:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum building occupant stem orhandle hrraMoos material
defined by tie Calandra, Municipal Code. Chapter 9. 12, and the Health and Safety
de. Section 35533(.)7 t�
C] Yes y�No
Will the applicant or future building occupant ,tie equipment or devices which
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handouts air contaminants as defined by the Day Area Air Quality Management
❑rax "Ever
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I have mW the hm'ydnt(s.=fish mpuimmenu under Clasper 6.95 of the Califor.
Bud
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 mater -As for inspection.
Signature o Applicant Date
All roof coverings to be Class "B" or better