00030046 LCITY OF,CUPERTINO PERMIT NO,
.. BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: "A I SANITARY NO. APPLICATION SUBMITTAL DATE
/O/ Ale• 263/ Y/�G�L 2/a'A(llriIGr
U ' C•R' MG / NIC CONTROL»
rz�s C'ur/O5, CA 9�091� I o
�0 0 ARCHITf:CI'/ENGINEER• - /� `- �r/j�• '•v i IIULDING PERMIT INFO
v'a LICENSED CONTRACTOR'S DECLARATION ,
<Z
O�=� 1 hereby aRrm Nu 1 tan licensed miler provrums,of Chapter 9 fco nemg Job Description•
1infu,Z- wlthscuon]o00)ofDlvistonlofW BYaleaaad Pr.fmiomcode,ad mY
s
llfmceedeRcm 7 / //�GI ✓/ '
3,A- Date Contractm
F O< ARCHITECTS DECLARATION
i3¢$ 1 understand my plen..hall be used m public reeds ^ s
i a e z
Lieam Prefin
_y asional OWN R-HUILDER .- .
DECLARATION ,
>' I hereby affirm met I am exempt from the Common's License Law for the
S f.11ounng rcawn (Sation]03 L5,Bmiesa ad Profcni.m Curie:Any my mcounty -
Which requires a penmt m comwm,ulcer,Improva,demohM,m npu any sweee
�a pnmrolmIssuance..lso rea,una.theappheamfor.empermittnmeasignedmucarent Sq. Ft. Floor Area Q�V�,a�Jlua���o9J1
.Nat he is l¢enaed pursuant to W pmvmlom ref W Convumrs Lmenu law(Chapin 9, .• k/rfI/ 'B/V
(c.mmencingwM Smuon]OOOI of Dlvnion3 o(Ne Hucinue and Professions Cmde)m APN Number Occupancy e
Wt he is exempt therefrom and the bun for the alleged exemption.Any violation of P y 'J P
Section 7031.5 by any yryficam fora pemut mi eem she applicant to a civil pammy of
or more than five hmMad dollars($500).
❑ nntion, • Required Inspections ,
Will d0the Work.ad Neshumure is et Intended m Offered for Wc(ShC 7044,Bunmu -
and Poleancm Code:The Comraaori Lt..Law does not apply to an amer of l
property h builds or tin Wren,and who does such work himself or Nrou h a
h w o Proves g
her own emDloYees,pmvlded Nu such Improvements on not intended or bRered for
We 1f,Mwer willh veth bublem rovement that did Out Wild irompleor
r-Mddm will have the burden or proving Nut he did not Mlld or improve(m for.
pose of hale.) ,
.co 1.m other of hie pee.704 an exclusively canvssi n;with:leanedonnburon to
construct the projet(Sec.]1314, Bolles aod property who ore Coden)The Contractors and
whom Law does nut apply
jets itbaofpratony wce Mddsrnmprovea thereon,and
.who convects for such P.lecm with econuecmr(Olmenad pursuant in the Contractors
L¢enu law ,
I an exempt now Sec. ,B A P C for Nis reuon' '
�O.
Wn'•' ^
WONXER'SCOMPENSATION DECLARATION
IAertbY affirm under perWry Of perjury one of hie fmll.,vin6 decluvuom - - -
„-As:have aod will meintun a Cen10cam of C.neeuo ulf-tnsum fm Workei a Compcn- -
timn, s provided fm by Secuon 3]00 of the Labor Code,for the perfoimeee of the
wor or wl.ch this permit is asued - , -
1 have and Will maintain Wrxi Compensmmn Imurenca,as ra tuud by Section
37M.f W Labor Code,for the pcmomane of W work far Which thor perm,,is ueund
My WOrk ,Sp pe sy �t�p�ytae tamer and Polley 61f
Camay`�/�TB��H/N� Policy No ^
CERTIFICATE OF EXEMPTION FROM WORXERS'
COMPENSATION INSURANCE
This action need not Mcumpletd lfthe perms is forone hundred dollars(SIM) '
Or less.)
I chntfy WDn tha'fonnuue of the Work for Which the pemut is mum,I mall
nm employ any perm.m any manner in as to become aubjeuo the Worken'Compeer-
..uon Laws of California Dem
Applicant -
NOTICE TO APPLICANT If,after meWng this Gemfcnc of Exemption,you should
become subject to Be Worker'.Compensation provmmns of the Labor Cade,yma must ,
forthwith comply with such provisions or this permit shall be d«med revoked
CONSTRUCTION LENDING AGENCY
O,� + 1herebyaRnnthin lheteisaconumctionlendingagencyfortheparfvmianceof -
Be work for which this permit is Issued(Sec.3097,Co.C.) IA
tw W., Lenders Nara•
W ^� I comfy the I have red this apphreMn and stain that the aM,e information is -
fL correct I agree to comply With all Ity and county mdmances and sum law.reLeong to
.7 Z budding conxvucuon,and hereby euth.nah reprmenwlves of this city in enter upon the
U O above-mentioned property for inspection proposes '
W,F (We)agree to eaves,indemnify and keep hundem din City of Cupenino.,,hit
O U liabilities.judgments.costs and expenses which may in my way accroe against laid city •. '
fsj in conmq.nricc of tang of th s pertnit.
AA APPLICANTUND WDg AND WII.LC ..1 WTHALLNON-POINT -
V SOURCIi REG 1 S.
Signanse o(Appl u t m
MATERIALS DISCLOSURE
Will III applicant or future Wilding occupant store or had le havrdous material R rj(Ofs
as defined by the Cupemno Munulpal Code,Chapter 9 11,ad thausalts and Safety
Cds,Section z553z(.)a / r , Type of Roof
❑Yes ESN. I.
All roofs shall be inspected prior to any roofing material being
Will the epPlicvlt or(mart Mlldine occupant use equipmem or devices which f
t hezardos,an contamimenu u deflncd by the Bay Area Ali Qmnry Management installed. If a roof is Installed without first obtaining an inspection
rah I.agree to remove all new materials for inspection: Applicant
❑Ye. � d
I heve•rted the huuduus matenate mlvlmnKnm voder C'Iuptv695 of use un ersta and will comply with all'non point source regulations.=,"n-by ty ode,Sett O5,35533 and 25534 1 uderswM Net,f the
MdGngd Iy emnt.Wert nmy rtzpomibiliry mtdi(y de occupant
ref the v moat be sun immix issuancemffic fee fees,
y Signature p t Date
' Owermau age
s All roof coverifigs to be Class"B"or better '
OFFICE "
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