00030111BUILDING DIVISION HERMIT 111 ^ Pia
BUILDINGADDRrSS rl.0 NI�h "�{�rI6
11 �6 �nrpx�s (�4 I Ills`A�ilc
OWNER'S NAME: I W Q fr J 1 A.•s C wa py11U�
PHONE: 6 �� l..�i�J T • �.
ARCHITECT/ENGINEER g 12,b
LICENSED CONTRACTOR'S DECLA.
rime that I sm licensed under provisions
in Nil
OWNER - BUILDER DECLARATION
I berms, affirm rho 1 an exempt from No Commences License Law for the
following Never. (Section 7031.5. Boaimss and Professions Code: Any city or county _
when nquirts a permit m connWCh alter. improve, demolish, in repair any museum
prim to its issuance. suits requimn the applicant for such permit W file ♦signed,Mm ni
Net he is licensed pursuant to she provisions of the Conrraroea License Lew (Chapter 9
(commencing wish Sector lW)of Divison J of the Busimu ad Pm(sso Code) o
Wt he is exempt therefrom anal the buffs for the alleged exemption. Any violation of
Sandra 7031.5 by any applicant for a permit subjects Na applicant to a civil penalty of
not mom then five hundred dollars ($500).
1,u owott of she propeny,ormy employ" wish wagesuttrir sole comNnsation,
wed dothe work, oulth swetumisnorintcd moflemdfor We(Sm.7 M,Busineu
and Professions Code: The Contractor', License law does not apply to an well a
propny who Wilds or improves Norton, and who does such work himself or 1 ,h
his own employees, provided Nu tech ice novemmu art ram imooked or offered for
We. If, however, do, building or im m
proveent is sold within one year ofcompletion, he
r•W ider will have Nc burden of proving that he did nor build or improve for pur-
poseof u W�J.
❑ 1. r or she prop", am exclusively conuachng with licensed eonmcmn to
construct Ne project (Sao , IOM. Business and Profeulons Cede:) The Contractors U.
tense law does not apply W an owner of propmy who Wilds in improves Name. and
who contracts for such ptojccu with aanmcm°h) licensed punwnt to too Contrectre s
License Law,
1 am exempt under See .B &P C for Nis rtaum
Goner Dero
WORKER'S COMPENSATION DECLARATION
1 hesuby affirm under panels, of perjury race of the following dmlaretiou:
El I have and will maintain a Car ificam of Co sent to self-insme for Wor Imes Compro
urine. as provided for by section 37M of No Labor Code, for the performance of the
work for which this Pemdt is issued.
❑ 1 have and will maintain Workees Compenutim, Imutumc. as required by Section
37M of the Labor Cade, for the performance of the work for which this parent is issued.
My Werr. 's Comp etionl seance cam Pold NOyn jar Izypf.0
CERTIFle OF Ili PrnoN FROM iWiORKERS'- �i�
COMPENSATION INSURANCE
(This secti nn need not be completed i f the permit is for one hundred dollars (4100)
or ku.)
I sandy that in the performance of the work for which this Nrmit is issued, I shall
not employ any Person in any manneno to the vh) m the Wooten Commn-
WionInwrofcali(omia.Da�_ �1e a
NOTICE NOTICE TO APPLICANT: I[ abet making ti Ni. Cisions f N Exemption, you should
become subject to the Workeea Compensation this provisions of No Labor Coke, you met
foMwiN comply wish such provisions or this pem,it shall ed deemed revoked.
CONSTRUCLON LENDING AGENCY
I hereby affirm Not Nero is a construction lending agency forthe peRomwce of
she work for which this Permit is issued (Sm. 3097, Cis, C.)
Unit,, a Name
Lmdat's Address
1 certify Nu 1 have reed this application and state the, she above information is
correct. l agree to comply with Of city aed mommy ordinances not sum laws elating an
building construction, aid hereby authodm reprommadvu of this city to enter upon the
above - mentioned Propeny (or inspection purposes.
(We) agree in save, indemnify and keep harmless the City of Cupertino against
liabiliues,judgmems, cos,a and expenses which may in any way mcrue ag mvi said City
in consequmm, of Ore granting of Nix mod.
�ignarvrt
HAZARDOUS am
US MATERIALS DISCLOSURE
Will the applicant or fume building o. Chapt erne or handle Health m mamdil
Crum, defied by the Cupertino Municipal Cade, Chapter 9.1; end Ne XcilN aM Safety
Section 23532(e)7
Yn
Will die applicant or future building occupant use equipment or devices which
emit hi aardoue air contaminants as defined by the Bay Aura Air Quality Management
District?
'❑YU I;w
I
have read the he arkus marmdals requirements under Chapter 6.95 of the Cali-
fornia Xaalth & Safety Cade. Sections 75505,15333 end! Z31a. I uokersued that if she
buildingdoesnotcumntlyhavea tenant,theitismymsq ibilitymnmify Nemp'aupant
of the rryuirtmcya5vv)ych must bg met poor to issuance of a Catilicale of Ommoag("Jn}
1,„ 1
Job Description
O 30 11
N/C CONTROL#
s�cyuucu umNcswnnm
-6n `.
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 materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of Applicant ' Date
OFFICE
All roof coverings to be Class "B" or better