00050066CITY OF CUPERTINO
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PERMrr No _
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BUILDING DIVISION PERMIT,
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❑UILDINC. ADDRE
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SANITARY NO
APPLICATION SUBMITTAL DATE
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ItCHITECTIENGINEER
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— LICENSED CONTRACTOR'S DECLARATION
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1 hereby aRrm "Al tlut I am licensed Mer pro ii m pure ( g
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Job Description
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wild $fAo.aCOB)O(DIVr o]Of eBusiness mId PlOfCUlOn9 Code my license 16
iafell forceeM eRcct .•
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License Li<.M
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ARCH17ECr S DECLARATION
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1 undentmd my Plan; WI leased as Puhlic rands
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Licensed Professional
OWNER- BIIBAER DECLARATION
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I hereby affirm Nat I not exempt from the Contract en License Law for the
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fut,towung reason (Section ]031 5, Business and Professions Cade Any city ar counry
Sq. Ft Floor Area
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which Au reA A permit m construct Man, Improve. demohalt r repair An, am.
rot issuance, also" ren the applicant( such permiu fl asgnedslatement
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that he is licensed pursuant to the provisions club, C ancmf License Law(Cheptnr9
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,(commencing with sand 7") ol'Division 3 ofthelluaimars andlraresaion.cade)m
that he Is exempt them d the basis f the II gad exemption. Any violahan of
APN/JNumbe -
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Occupancy •I�, e
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Sold. 70315 by any applicant fm a somur subjecta the appllcantto a civil penalty of
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t more man five hurdrtd dollars ($500).
[7 as owver of me prvpeny,mmy cmPloyanv wire wagesu Weir sale compenutian.
', Required Inspections .
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will dothe work, andtheswcture is not intended mOBertd faraale(See 7W, Business
And Prof,uiom Code: The Conmeter, License Law eoea am apply m An ..A, of
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pmpcny who builds or improves thereon, W who does such work himself or through
his own employe., provided that such impimemrnrs . am intended An offered for
snla if, hinsi the Wilding a enuuOld vdid n ut
Wild or inapeoem
proving mat he did nth build m improve for put,
the ur en of .
ownephilder ill have the burden
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pose feel ) r I
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❑ 1 u net Of pmpenY, ern exclusively contracting with li Thal cmmenc
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And Professions Code:) The COntiacmn,
construct iAeprof Ppplyoan
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who Wilds and
t apply je ts owns of progeny who bud r improver memo" Arid
tense V owner
when .Low for ch Projects wiseewnwemr (s)IicenvG pars ntmm Contracmtn
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License V
❑lam exempt under Sm. B &PCfor tars reason
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owner Data
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WORKERS COMPENSATION DECLARATION '.
4hcrebyaffirmunderpenaltyofp erjury co, clue, following declanuond.
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hp I have and will maintain aCenificam of Consent to self -insure for Worker's Campion.
atiom u Provided for by Section 3]00 0( the Labor Code, for the performance of me
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w k for which this emus is issued.
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I have end will maintain Waker's Compensation Insurance, u required Section
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OOofthelabor Code, for me performance of the wort farwlimlyll permit is issued.
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MY W k O tp et 1 stir - .e catnor nd Policy tin dfe
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RTIFICATE OF EXEMPTION FRUM��.
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COMPENSATION INSURANCE
(Thin section nand not h completed if me pemut is f rem, hundred dollars (SIM)
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I coolly Out in me perrformmccofine work for which di apimut is issued, I shall
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not employ Any person in any manner An as to become Rquean to the Worker' Compmo-
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sation Lawsof Califomia.Dam
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APplicanl
NOTICE TO APPLICANT If, after making min Caoificato of Exemption, You should
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become subject to the Wmtd. Compensation Frivisiona of thn Labor Code, you man
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forthwith comply with ... h provisions or this pnornit.hall be canted invoked,
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4 - CONSTRUCTION LENDING AGENCY
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I hereby affirm that then is a construction lending agency for the performuce of
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me mk f hmh mu pertains issued ec (S 309], Civ C )
. Lenders Name
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Lenders AddseA
1 certify that I have read this application and state dial me above information is
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comect agree to 1 ag empty with all city Aid county ordinances And state laws relating to
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building construction, and hereby Audience representatives of Ms city to enter Aura N
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above - mentioned Property for inspection P" s
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(We) agree m save, indemnify an p ar the of Cupenine against
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which they in any way eccmeagalnv aid City
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afffin eata'Andexpc
in conmquence of the 8ranting of
APPLICANT UN :RSTAN . AND WILL COMPLY WITH ALL NON- INT.
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SOURCEREG .ATION
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Signature of A PP le Or - Dm
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RD OU S MATERIALS DISCLOSURE '
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Will then
Applicant 6 occupant
u defined Cupertino e,Captnoreoronalte Health And Sdety
Sue by the Cupeoino Municipal Cade, Chapter 9.12, real the Health and Safety
Code. santimi 25532(.)?
Type of.Roof
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Yes No
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Will the Applicant or future Wilding occupant use equipment ordm;res which
emit haradous air centmnitunta as defined by the Bay Area Air Quality MAaagement
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All roofs shall be inspected prior to any roofing material being
ilistalled.•If a roof is installed withou irstlobtaining an inspection
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II a ree'to "remove all new materials for irispection. Applicant
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have onsi'te havobae ma nal:re i rearm real r up 5.95, the Cali.
understands and will comply with all non point source regulations.
forme Health &Safety Code, Secuom 2s305. 15333 sad 23534 1 understand Nv'f um
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building does not cumnuy eveaten MY resNonsiminy to notify the occupant
of me raluinementa whit t tar pile i iea..on ofa Certificate u
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Signature of Applicant Date _
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Owner or euthonzed age Oats
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V All roof coverings to be Class "B "-or better'
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