00020067BUILDING DIVISION PERMIT
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LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Nat 1 ten licensed under provisions of Chapter 9 (commencing
wiNSalion]000)ofDivi 'onlof the Busim"ud Rofessio C .antro licemeis
in full force and effect.
Lice. Lic.N
Date Cona.cor
R TITECrS DECLARATIO
1 understand my plana "I W used u public rends
Licensed Profcasioml
OWNER -BUILDER DECLARATION
1 hereby affirm the, 1 em exempt from the Cmaramarr License law for the
following session (Section 7031.5, Business and Proforrian Cada Any city m county
which rectums a permit ,o construct, alter. Improve. demolish, or tepes my suracture
prior m its i.asuance, dso requires dto.pplicanr for such pemut e. file a signor amcmcm,
that he is llooded pusuam to the provisions of Ne Contra"ors License law (Chapter 9
(commencing with Section 7E W) of Division l of,he Bush[.. and Pofeariona Cade) or
that he is eaempt N"efmrt and the basis for the allew exemption. Any violation of
Section 7031.5 by any applium for a permit subjects the applicam to a civil porosity of
not mote than five hundred dollar ($500).
(] I. as owpet of tW property. of my empleyecr with wag" an their sole consternation.
will do Ne work, and the structure is not emended or offered for we (Sec. 7044, Bso mss
and Professions Code: Thi, Contractor's License law docs nm apply to an owner d
property who builds or un mves thereon, and who doer such work himself or though
his own employees, provided that such improvements An, and intended ce offend for
We. if, however, rte building or improvement is sold within one year of completion. to
owmr.W ilder will have the burden of moving that W did not Wild or improve for ptn-
pose w we ).
rl I, u own" of the property. un exclusively contracting with Emitted contractors in
continuer the poj.ct (S.. Itdi, Business and Professions Cadet) The Contractor'. Li-
cense law door out apply to ted owner of property w W build. or improv" thereon, aid
who contracts for such projects with acon nabods) li"nud pursuant in the Contractors
License Law.
1 am exempt order Sec. . B A, P C for this reason
Owner Date
' WORKER'S COMPENSATION DECLARATION
1 hereby Mo. under partly of perjury one of tho following declare iam:
I have "will mainuio a Comfiest( of Correa to wf.lnsuo for WnrkersCompem-
ution, uprovided for by Salon ll00 of the labor Code, for the petfeemance of the
rk fm which thin pent, is issued.
1 have and will maintain Wdo es Compensation Imurade, ss required by Section
Worth. Laden Code, for the performance dtho work for which �this permit iss ifssued.
My uumdo Compemato sutgnee tamer and Policy!2117I_S!).S_�
C rier: tri a _ /_pis Policy No.:
COMPENSATION INSURANCE
(Th i s secdo. need not be completed I f the .,is for Od hundred ped lar (SIN)
or lose.)
1 certify that in the Illuminati of the wmk for which this permit is issued. I shall
not employ any peron in any msoner on as m become subject to Ne Warkerf Compen-
sation laws of Coliforms. Dale
Applicant
NOTICE TO APPLICANT': If. after making this Certificate of E.emplime, you should
become, subject to the Wdkces Compensation provisions of the Labor Code, you most
foMwith comply with such provision or shite petmin shall be deemed revoked.
CONTR
SUCTION LENDING AGENCY
Q Q I Wreby affirm that doer iso constuNon lending agency for the performance of
z ythe work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
} laeder'a Addrerr
f+7E I certify than 1 have rad this application and sure tea, the above information is
G. contact. 1 agree to comply with all city sod county ordinates and sou laws relating to
C z building construction, and lherby.saMmee representative, offs city he enter upon the
U O above-memimed property for inspection purposes.
is. P (We).gre to rave, inda enify and keep to rmler. NK City of Cupertino agaimt
c.i liabilities, judgments, emu and ",loses which may in any any accrue Main, said City
} (4 in conrquence of the granting of this permit.
(• y I'
APPLICANUNDIiRSi'ANDS AND Wit.[. I
T. COMPLY WE ALL NON -POI Nr
U Z SOURCE: REGULATIONS.
igneturt ppbcanruc ream Date
H lox S MATERIALS DISCLOSURE
Wlltheappllca or fmure Wilding oocupenlftde or handle haauddu muenil
M defined by the C9 nitro Municipd Cade, Chapter 9.12, and the Health and Safely
Code, S"tion 255 p)^
❑Yes ek
W II Nc applic.n, or fmure Wilding accupent rte equipment or devices which
W, Ir"rdous at. eontamin.nts es defined by the Bay Arca Air Quliry Managemeol
Attiml
❑ yeso
I Nve eased to hawdoo, matedils on,irtnem a under Chapter 6.95 of the Call.
forms HCWh A, Safety Cade. Seainew 25505, 25511 and 25534. I understand ,het if the
Wilding coca not currently lava . intent. died it is my responsibility to notify the occupant
ohne reuu'v.rrcnu wkich muss be met oda m i.numRe of a Ceni&ate n(OccmtanhaY.
(r�
Sq. Ft. Floor Area
Re -roofs
Type of Roof
(0002-0,0/'o %
Job Description
SANITARYNO 1,APPLICATIQN SUBMrITAL DATE
D'Z1)0
NIC CONTROL
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
understands and will comply with all non point source regulations.
Signature of Applicant
OFFICE
All roof
Date
to be Class "B" or better