00040148. a- a' .ia M...,..,
BUILDING DIISON PERMIT
CONTRACTOR INFORMATION:
LICENSED CONTRACroR'S DECLARATION
I hereby aRrce dw 1 are licensed under provisions of Chapter 9
with Section 7M) ofDivision3 ' f IN Business and Peofesiwu Code, an
in full fort -an ff tar 1 �y oQ
Date- lase V _Lr.L. Co.—
DeR_ ^ Contr.ctor
ARCHITECTS DECLARATI N
I undmtnd my plans MJI W used as public rtcatds
Licamsd professional
OW NER- BUILDER DECLARATION
1 hereby affirm that 1 ad, exempt from the Contractor's License Law fm the
following teams. (Section 9031.5. Business and ProOrssions Code: Any city a tummy
which requires a Permit to construct. alter, improve, demolish, in repair any amdctme
prior ne its issuance, alto "Will IN applicant fortieth pemut to Isle a.igad aetmaire
that be is liumed pueuaoa to the provitinms orde Cmounors Licenu taw (Chapter 9
(commencing with Section 1000) of Division 3 of the Busimas and profeuiou Cad.) or
then he Is manryt therefrom and to basis for the alleged Cu mp imi. Any vmlauon of
Section 7031.5 by any applicant fora permit subjects We applicant m a civil penalty of
t mmc then five hundred dollars (53001.
❑ 1, as owner of the propen, or mY employees with wages a Weir We mmpmassum,
will clothe work, uhd do swcture is non intended m oRerd for We (Sec. 7014. Business
and professions Cade: The Conductor's License Law does trot apply to an owner a
property wW builds or improves thereon, and who does such work himself a though
his own employees, pmvidd that such improvements are not intended or offered for
We. If, however. thN, building or improvement Is sold within one year of completion, de
owner- builder will have the Wrden a proving that he did non Wild or impose for phu-
pose of We.).
I. u owner of de, propnY• and exclusively condutor, with licensed mntramon be
construct the Project (Sec. 7w, Business, ad professions Cooke) IN Comystem's Li-
cenu Law does nut apply m an owner of property who builds or imposes theemm, and
who corns for such projects with a mouutor(s) licensed pursuant he the Convector's
License law.
❑ 1 any ..am, moral Sx. . B B P C for this mason
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby dorm und.r, penalty of perjury one of the following dedamirea
r1 have end will low.. C.Afiwa of Consent to W6irmle forwork e.compn-
ed. as Provided for by Smuon 37W of the LaWr Code, for the perfemeae of the
or which Nis permit is issued.
w 1 have end will maintain Wakes Compie titian Imur -. u returned d by Section
3700 of the Isbm Code, for tale performance of the work for which this permit is issued.
MY WorMM//�g's CoWW jj��°s�hh�o,rt IIn�ns��urm.n�a carrier and Policy number t s 1I OI
Camcc.(„a.CERTdZ.Rf44'L_PO N NO M W �_ ^sY
CERTIFICATE D FJ(EMPTIINN FROM WORKERS'
COM PENSN INSURAN
('his section sad not W cmnPleradif W permit is
rarmehmdMdotlen ($100)
alma.)
1 codify that in the performance of the work for which thin pemul is issued, I shall
not employ any person in any manner m .,no become subject o th. Wotan' C.I.-
.a. Laws OLCOlitnmia. [111 a Mvr iIL
A icant Y••w��a.a�As���s x
NOTICE TO APPI.gCANT: If, after m.ki this Cenifcate of Exemption, you should
became subjcot to the Workers Compensation provisions of the LaWr Code, you most
forthwith comply with mch provisions or this Permit shall W domed evoked.
CONSTRUCTION LENDING AGENCY
1 hands, affirm Wm tee is a common ion lending agency for the perfmnanee of
Iha work for which this p.mut is issued (Sec. 3097. Cry. Q
lends, Name
Lenders Address
1 certify that 1 have lead this application and soon that the above information is
correct. I agree to comply with ell city and county aNlumces and state laws elating to
building emstruction, and hereby authorise epresentmives of this city to enter upon the
abovrmentio ed property fm inspation purposes.
(We) agree re Live, indemnify aor keep harmless the City of Cuadira against
liabilities, judgments, cost end expires which may in any way same against said City
r qu
in conemee of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI Fit All. NONA)I N
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m lium a Wilding acupmu rd
lore or handle hazardous material
u dafind by the Cupetino Municipal Coe. Chapter 9.12, end the H.alth and Safety
Code, Section 8532(a)?
❑Yes ON.
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminant as defined by the Bay Arc. Air Quality Management
(Murrill?
❑Yes -1 No
1 have red Ile hilarious Irurmals restilern.ns under Chapter 695 of the Cali -
fomis Hearth Al Safety Code. Sections 25505. 25533 ted 8534.1 understand this if the
Wilting does non currently have n mars., threats my Rsponsibilily to nmlfy the aCCup..
of the mWiremenu which mum W met prim m iDUance of s Certificate of Oecupeay.
Owner err suNorild agent Dal.
S /6AJ DDS/ 6r3
0P. o - Bx �fS9 0
Mozl`r4aO t Cam}
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Job Description
000 t4001 r�
NIC
way 1`-.jtV7P-T
f t 1
A • �, �1f / ; / y
AWFA
/V O
I 9- Fly/
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.
4-19-Oo
atu of Applicant �( Date
Allaroo coveru3gs o e Class "B" or better
OFFICE