04100102CITY OF CUPERT[NO -
"BUILDING DIVISION PERMIT'.
DOUGLAS ROSS
ARCHIIEC (ENGINEER:
1.
04100102
LICENSED CONTRACTOR'S DECLARATION
- - ..' Job DeSCilpuOn
j1 DY aRrm that I m IkemW umkr pmW;Iqu a(CNPmr 9 (cemmewing
with Jia ]x11) of DlWdon lafthe BtiAlnasand➢IbQuluus Codedndmyllcenseis
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LkanmClauin f�`RCe Lk.0 ✓✓ �V/
--REVISION--STURCTURAL.MODIF./
Data ContraARCHTIECI'SDctor N
ECrS ECLAR N
-NO NEW PERMIT ISSUED/ORIG. #04050174
IV�craund my p4naahul
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby Affirm Out I.am exempt from the Cammeno's License law for Ne
following wan. (Section 7031b. Buslwss and Professions Code: Any city or county,
which mgums • permit in Camuuu, Alta improve, demnRsb. w repo, any Mosetme
-
prior in its issuance. abu requires the applicant for such permit to Bic a signed summent
that M is licensed pursuant to he provisions of she Contncmr's Lianas Law (Chapter 9
- _ Sq. Ft. Floor Area
- r+. Valuatii
(Commencing with Section 70110)9Division 3 of the Business and Prormsians Code) or
-
Out he is exempt Ncmfton and Ne bub fes the Alleged exemption. Any violation of
Section 70313 by any applicant for • permit subject, the applicant to a civil penally of
APN Number
Occupancy
mat mom Nan five hundred dollar (L3017).
❑I,Ma ofdmpmpmy,wmyemployeeswiNmps" ekwkmmper Um.
31620084.00
will do the work and the suucture is not intended or Offered fes uk(Sm. 7044• BusinessRegtyted
.. -
Ins actions
p
and Profemlwu Code: The Commutes. LiCvue Law dam wt apply W an --of
property who bulldsarlmprovo thereon. and whodoassich work himselfar Wauth his
_ _ .
thebud Natswhimg proRmd fes Wn
smwtiild
however. the building or Improvement is sold within one year of completion, Ne owner-
\
orI of
Wilder will have the buNan of proving Nu k did not bold w improv for purpose or
Wil.will have But k
-
u .l.
ting with licensed coic oc;
a owner of the propenY• am ealusnely cant,¢ mto
7061. Business and Professions Code:) Ths Contractors LI-
comuun the pmjew (Sec.
Co.. Law it. nnl apply In an owner of property who Wilds ser I me. dnennt. and,
. .
who contract, for such projects with a contractor(s) IiCmsed Punt to the Contractors
.
License I.
I W exempt under Sae , B k P C for tiffs roan
F1 hereby dRrm under Penury of perjury ane Clubs following declarations: -
I haw and will mumain accruficam.f Consent toselbinare far Workers Camper
sa0on, see provided for by Section 3700 of the Labor Code, far the performance of the
work for which this pmnil is issued.
❑ 1 have and will munuin Workrli Compemulon Insurance, as required by Section
3700 ft, Labor Code.(w Ne performance of Ne Werk far which Nis permit iiimud. r... .. -
M Orktrs pensatio. Inwnece carrierane Policyn ram:
W i ��,�, _, i - i - m.,
(Thissection need wt becomplemd Ir Ne permit Ia fame bundmddollm (LIOO)
or lass.)
I certlf-v Net in the performance of the work for which this Permit is issued. 1 m9l not
employ any person in any manwr an as to become abject to the WodmWComM—don
Laws of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this Cci iOute of Exemption, you should
become subject N Ne Workcr1 Compensation provisions of the Labor Code, you mus
.J O forthwith amply with such provisions Or this permit dull W doomed rawkcd.
z CONSTRUCTION LENDING AGENCY
(-, Ihereby affirm that Nem is a construction lendingegemy for dm performance of
it Ne work fes which this permit Is issued (Sec. 3097, Cl, C.)
W Q Lenders Name
=1 z Lenders Adds -
C7 Q 1 cenlfy that I haw read Out application And sou that the above information is
IX. !w correct. I agree to comply with all city and county ordinances and state law mhdng N
0 building conumction, and hereby auNodm mismsexemovca of this city to COW Upon the
W ahow-mentioned Property for inspection purposes
(We) agree to ave, indemnify and kap haonsi s the City of Cupertino agaWt
1 Ilabilides, judgment,. costs and expenses which may In any my acerm Against said City
U Z in consequence of the trantint of this pemriL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Si um of Appii.VC r Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant more Or land c harerdous ma¢dal
as defined by the Cupertino Municipal Code. Chapter 9. U. and the Health +lid Safety
. Section 23532(.)7 - All roofs shall be inspected prior to any roofing material being installed.
rue o
Will the applicant Crtmurc Handing occupant ukc equipment lir devices which If a roof is installed without first obtaining an inspection, I agree to remove
it haadous air contaminants a defined by the Bay Area Air Quality Management all new materials for inspection.
District?
t '.
oro �S
Wilding
not currently hive a mom, Nat it b my responsibility to notify Ne aaupant of the
remain which raw be met prior to Issuance Ora Certificate of oeCupanry. Signature of Applicant Date
��44 11 91-0�f All roof coverings to be Class "B" or better
err authorized agent 1'gatn _