00030218BUILDING DIVISION PERMIT
BUILDINGADDRESS:
s
LICENSED CONTRAVDR'S DECLARATIOtf
1 hereby aRrm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7BB01ofDivision 3 of rhe Bminws and Rofeuioru Code.
"my liana is
in full force and effect.
License Clue Lir. as
Date Course
FtID S DECLARATION
II W ureal is public records
oar
ER -BUILDER DECLARATION
61 hereby affirrinAhat I and exempt from the Contractors License taw for the
following maven. (Section 7031.5. Business and PmPosslons Cuda: Any city or county
which re, ices is permit to contract, eller, improve, demolish, or reed;=.
any ,wawa
prior m its iummer. dw requires the whicant for Ruch permit m file a signed oma=
Net Inc is jummad pursuant to the provisions of the Contractor's Licence Law (Chapter 9
(commencing with Satian 7000) of Division 3 of the Business and Professiau Code) a
that he is ascmpt thrmfmm W IN basis for the alleged exemption. A, violation of
Section 70315 by any applicant for a Formal subjects 0m applicant 10 a civil peu1tY of
no more than five hundred dollars ($500).
I,uowvaofine pmpnmetem is empoymwidfromesas Neu ani<mmpenudon.
will do pe work and dm alsucm ais na imetdcdm au, do forsole (Sec. 70oe,owner a
Rod Proper wZu Code: The oyes thereon,
Lianas law dors nor reply s lf through of
property who builds or improve Ruch i pr who dors such were hied . ti through
his own gvwavvaa, provided Bw such improvements ase not intended a offered for
We. If. M1owev will l buildingorimpmveovinl isgoldyear imrrove for red
par-
of
Ralder will hove dm Nrdcn of moving thaI he did acs Wild m improve for pm-
poa au uta).
I, u l me F of the See7Cproperty, am sine exclusively contracting with licensed mnratan m
construct the project (Sec. elan, Boniness and polarity
who m Code:) The Contractor's I.I.
come not dao Out apply he an owner of property eccbuilds m imWthnend
ovea on, a
whoeontracts fa such ptojau with a conliactar(a) licensed
nsed pursuer an the Convector's
Liana Law.
❑ I em exempt undo Sec. . B A P C for Nis won
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under poi of perjury one of Bre following dalwtiou:
Iheve ane will maintdneCenificate ofConsmuo al6inwrt for Woken Compcm
satlon, a provided for by Sado. 3700 of the Labor Calc, for the performance of the
work for which Nis permit is issued.
1 have and will maintain Wakees Compensation Insurance, u required by Section
3700 of IN labor Code. for the performance of the wok for which this permit u Wood.
My Worker's Compensation Insurance carrier and Policy number mc:
Carrier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section hard as N completed ifineperem, is fafatehondred dollen (5100)
or less.)
I cenify that in the performance of the work for which this permit is issued, I shall
not employ any from in any menhar go as to become subject to the Worken' Compen-
sation laws of California. Date
Applicant
NODCE 7D APPLICANT: If, after making this Certificate of Exemption. you should
become subject to the Waders Compensation previsions of the Lidg r Code. you must
tomb% ash comply with such provisions or this permh shall be domed rcvuked,
CONMUC ION LENDING AGENCY
1 barely, sffiw that them is R...do. lending agency for the permormi of
me work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
Leaders Address
I amity that I have read this apoicalim, and owe mal IN above of—fires Is
correct. l Rorer to ranPly with dl city end county ordwnces W Rute hos relating to
building couwction, and hereby authmia reprou n i iver of this city to enter upon Bm
abrrva-mentioned properly for inspection purpoms.
(We) agree to nave, indemnify and kap harmless the City of Cupertino against
liebilitir,tal,mema, costs and expenas which m ay in any way same against said City
in mrs cqueoa of the ginning of this permit.
H R US MATERIALS DISCLOSURE
WJI Ne septic to court Wilding acuportlu a or tunNe haurdau material
as defined by the Cu 2"building"o'Cu'part
i l CoalChp[er 9.12, and me HedN and Safety
Code, Section 255320mp
Y.
Will Ne applicis ouse e9uipment or devices which
mit hauMous dr conwninanu es lefined by the Bay Area Au Queliry Management
District)
❑Yes
I have rand do dors wlmde mquirtta under Chapter 693 of Ne li-
fomia Heatllr&)afety, , Smr. r�'�1s .SSJ)S'x3IIXOOVSM3 1 underyeM Nar i Ne
CONTRACTOR
C'�,,�F.
C-1
Job Description
--f:.,.,m-- - -__
Goo30,5�-t8`
Sq. FL Floor Area ,/ Valuation TO
�-
-02—
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 a ree to remove all new materials for inspection. Applicant
understands and will comply with all non point source regulations.
Signature of Applicant
OFFICE
All roof
Date
to be Class `B" or better