00090084l•u 1 VP %-rcnk Billy
tsl1D.DIrvG nrvtSrnN PERMIT CONTRACTOR INFORMATION:
BUILDING ADDHPSS.
LICENSED CONTRACTOR'S DECLARATION
I eucby affirm dee I ant hcciued under pravhion, of Chapter 9 mulannendny
With Section)OlXp of Division 3 nine, Bruin,.. andlae"Joira Cade.:ad my license
fore and a Z Q
I.in fulliacurqb�In l9
Dane L o QO S DECLAr OC
ARCHrrECT'S DIiC,iii, N
I I'ndcocmd ny pinn..hnll he nasi av pnblie',cord.
OWNERdlUILDER IA.( LARATION
I hereby effort that 1 um exempt from the Commcmr's Licence Law for the
following reason. section 7031.5, Badness and Profession. Code: Any city mcounty
which mulles a permit m mm.lnm6 atm', iwm
prove, dalish, or repair any .structure
prior m its issuance, at,, requites the applicant lin Inch Penn m file a signed .Statement
that he is licenwd par mat 10 the awiaon, of the cmnrui License Lax' (chapter 9
(m cooing with Section 700ttof Dio ... t3afhelinins,, and Prufe, iota Calc)
or mat he is exempt therefrom Bind the basis for the alleged exemption. Any viulutiou
of Section 7031.5 by any applicant for a pemtit subjects the upplicant no a civil penalty
at tantrum IIran five hundred dollars ($5110).
❑ [,a% owner of the prnluny. or my entplayeea with wages as their. -le nmtgenselion.
will do the work, and the nfracture is not lammed nr ullemd lit, sale (Sec. )Ina,
Business and Pmmeians Cade: me contractor's License Law doe, not apply ,, an
ow ter of pmpeny Who builds or elm es thereon, and who does Such work himself
or mmugh his own entployces pnvided that such intp o'cownu m'e not imcndod ar
offered for sale. If, how`s,', the building or immurement is sold within one year of
uuntpininn, the oise-h older will have th, htnden of greying but he did trot build or
improve lid purrytu of sale.).
❑ I. as owtmr of the property. ten exclosivcly contracting wilt loaned contractors to
construct the pmjocl (See 7144. Business and Pmfasion Gdc:l 9'he Com atiot ,
License Low does not apply to an owncr of progeny who guilds or Impmvcs themon,
and who conmmis h,r Such pmjccb with uummmnaq,) Keened pm,uam to the
Concurs License Law.
❑ I am exempt under See. . B k I' C for his re ... m
owner Late
WOR K ERIS COMPENS All ION DECLARATION
I hereby alfinn under penally of perjury one of the fallowing declaration,
I have and will oil tidon n Cm ffl,.,n of Cuf.cnl est self -insure ler Wodus
Compensation, Its provided I'or by Section 3700 of the Lett Calc. for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compenation Insurance, as required by Sweet
)(X) of the L:mor Code, for he pcborm ance of the work for which this permit is
issued. My Workd'. Camp,nml mon Insumo,, caner and Policy feeder are
COMPENSATION
Thix.saNan nem nal be cmnplcled II the pefnin is trate handed 6oll:u.
o IrxB nr IcuJ
1,roily that in the perl'urfouncc of the work Ior wblch do, pennil is I,otod, l
shill nal employ any Incessant in are, founder m as to became mbjeet to the Workers'
Comlrnsmion Laws of Call Errfla. Date
Alidicam
NOTICE TO APPLICANT: If. after snaking his Cenifica r of Exemption, you should
becnme.ubjcel to the Work,,, Cotnpemudnn pro v.....0 al'the Labor Calc, you meet
furthx 7th <mnply with such trr veiuns sur (If, pfron, shall be, deemed revoked.
CONSI'RUCIION I.IINDING AGENCY
1 hereby affimt than there is it construction lending agency Ibr the perimumee
of the work for Which this pennon is i..ued (Sec. 3190, Civ. C.)
Under's Address
I ,edify that I las, ,ad be
counsel, I agree to comply with all
luhilide" jud"reno. Liras
Cke in.amamena M he
and .num hat the above inlimnnlion in
my ordinances and state laws relating
�preaenmtims of his city a enter upon
n o.
namdean the Coy of Cupertinoai
may in any way acct¢ againstst aid
it.
OMPLY WITH ALL NOb'-PQlyr
W
Signature of AppreaMcantmc 11 - • - - - I Re -roofs
HAZARDOUS MATERIALS DISCLOSURE
Willne... beamar inure buildifgu<upwn sonar handle hmnflou. mmemd Type of Roof
as defined by the Cnperemo hf rinciled Code. Chapter 912, and the Health and Safely
Coda Semum 25532INI /
❑Yet L�'N All roofs shall be inspected prior to any roofing material being installed.
Will he applicant of retom culthug oc,np:mt lee egniputert nr Jneicea Which If a roof is installed without first obtaining an inspection, I agree to remove
�mit hvurdous air contaminants S% defined by the stay Are., Air Qualiy Management
i.tderrall new materials for inspection. Applicant understands and will comply with
EI Yes e all non -point source regulations.
I have read the hauudm% materials requirements under Clingier 6.95 of the
Colillmnia IlcmlL d Safety Calc. Sectlons 255115,25533 and 255',14. 1 uudmsemd hot
if be building does rot currently enc a manor. that it is if, re,00ibiby no notify the
cupam o'thc ler:. using which must he an prior to issuance of a C.enBieme of
Signature of Applicant Date
Dwner ,,mlhu, edk�} . ' n� All roof.coverings to be Class "B" or better
No.
di.IIG ELECTPLUMB MCCII
Job Description
T/0 SHAKES, ADD 30# FELT, CLASS B HEAL
Inspections
305
— FRAME
307 —
INSULATION
601
— ROOF TEAR OFF
602
— ROOF PLYWOOD NAIL
603
— ROOF BATTENS
604 —
ROOF IN—PROGRESS
Issued by: Date
OFFICE