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FY OF CUPERTINO
WELDING DIVISION PERMIT
Sao -i7 a . t
LICENSED COMRACIOR'S DECLARATION
I hereby affirm that I am liccwed under provisions of Chapter 9 (eomneneing
with Section 7000)of Diviaion 3Of Ne Bminesa and professions Cade, and., liars, is
in foil forte and effect. 7O2 -q77
Deter Licenere Cie Cony¢ A1g5 .45 PArd.,
ARCHITE.. 'S DECLARATION
I understand my plain shall W Mas ublic records
Licensed! professional
OWNER -BUR ER DECLARATION
1 hereby affirm dust I am exempt from Ne Contractess License Law for the
following reason. (Section 703 I.S. Bmincss and Pmfeasions Cade: Any city or county
wnich no,wres a permit to Conswct. ai.r, improve, demolish, or repair my mucmre
prim to its issuance, also rtquires the applicant formch person to file a signed statement
Jut he is Iiaved pumanno the provisions of to communities License law (Chapter 9
(commencing with Section TOW) of Division of the Business and protrusions Code) in
that he is exempt theef en and to basis for the alleged exemption. My violence of
Section 1031.5 by any applicant for a permit subjects the applicant m a civil penalty of
nm come than Fine naMmd dollar (5500).
ownerfmd popany, or my cmPloyas with wagcx a theirmle compawdon.
will doth. work tad Ne he Com is rot B LiceMoroRerM fm me (Sec. u, an Business
and My who
CMO: The Conmemen License law docs rot apply m if owner of
his my who builds or impova t rush i and who dues such woak bled or li through
alfor
his own employees. provided that such mentis old w aR nor intended o offered for
me. IE hmvercn Jae Wiling or improvement is told within one you of completion, the
owner -Wilde, will have de huNen of mvine due, W did Be, Wild ce improve for For-
poseofine.).
1, Be owner of the pnormt,, am exclusively contracting with licensed coneamo a to
construct the project (Sec 70,14, Business and Professions Cede:) The ConPanor'5li-
Cense law does not apply to an owner of poperty win Wada nr improv. maaecn. mit
who contracts for men pmjecu with a commmm(p licensed punumt to the Contractors
Littre Law.
❑ 1 em exempt under Sec. . B A P C for this maxon
nu Date
WORKER'S COMPENSATION DECLARATION
1 hertby all,. under, nal
pety of perimy one of the following declamtiwu:
1 have and will maintain a Cc^ificam of Commen 10 self-inwne for Workers Compcm
action, u provided for by Section 3100 of the labor Code, for the p:rimmanee of the
r1$for which this permit is issued.
ja'I Ibaw and will maintain Waters Compensation Insutmee. es required by Section
37M fNe Labor Code, for to perfomomen of Jn work for which this permit is issued.
My Wodr [ mppccmotion Imurmee easier and Po1'my um u
Comer:KOIYlA fT n/HP. Policy No.:Ij-��{'�Z
CERTIFICATE OF E%EMPMON FROM WORKERS'
COMPENSATION INSURANCE
(This satin. heed M W completed if thepenin is fononc hushed dollen ($100)
Or las.)
I cenify wt in the pxif.c, of Ne work fm.hich do.perem is ismed. I shell
not emvloy any p O.B in any manner an as to become 1-biau0 the Werkea' CotnPen-
mtion laws of California. Date
Applicant
NOTICE TO APPLICAM': If. afar making Nis Certificate of E.B.P ncn. you should
hccomc subject to the Workers Compenamim provisions Of the Labor Cede, yw must
fOMwit, comply with each provisions or thio permit shall W caned evoked.
CONSfRUCf1ON LENDING AGENCY
1 hereby uffrm tat then is a commotion lending agency for the performance of
the work for which this mnit is isnad (Sec.3097, Civ, C.)
Lenders Name
Lenders Adders
I cenify that I have read this application and sate that to above utomution is
correct. I agree to Comply with JI city and county odWnc , and auto laws Man, to
building ... stmed... and Waby authorise repencluddves of this any to coon upon the
.Wvo-mentioned property, for inspection'm,swea.
(We) Agra to rave, indemnify and kap hnmlen the City of Cupertino against
Iialulims.iMgomms. Creta and eapenas which may in my way accrue against said City
in comequcae of to grouting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI I If ALL NON MINT
SOURCE REOOT1 MONS.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ufmum Wilding neCol., strnc or handle hmecdoua material
as defined by to Cupe^im MunicipN Cede, Chapter 9.12, end to Ham and Safer
Coder, Section 25532(.)? /
❑Yea iCn
Will the suplirot or fume Wilding occupant use equipment Or dcviCar wMm
t ha cu doss, at eonuunin.no as cafted by Ne Bay Arca Ak Quality Management
n1 1�Ycs
1 ave read the heaardou. maarials mqui^ments under Caper 6,95 of fall Cali -
forma Health A Safety Code, Simmons 25505.25533 Brut 25530. I unce^und that if the
Willing deaod cu d, aver B team[. that it is my eapomibility ...try the occupant
Bfta rapie m mpriar to kuuerce afaC'd�I `c y.
�th
euo{t. gent n II� Dora
CONTRACTOR INFORMATION:
SAV 14 T .dS Sc;,r- I,y7c4
A eco ck. c^miuga o tea-►-
S'O kZ G W
l.oS ALTPS,Gd a �I4o22
Job Description
Q Do u5
3 /-o
NIC CONTROL#
Ki,iBIoC4. /5=cl,-TLC*Agz "% Gt(Lourlo F���iz
L,vflAC,j oM {-,lTGkrkC-laL5(S-Cc.T4C=` o�`t
M5T(Z Gaxgravr1 5U-6to 400CClo�
wiB
Re -roofs Re -roofs
Type of Roof
/83. Z 7 -
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
understa ds and will comply with all non point source regulations.
Signature plicant Dates I t�
OFFICE
All roof coverings to be Class "B" or better