00030064 CITY OF CUPE - PERMIT3O O
BUILDING DIVISION
stoN PERMIT COO NTRA TOR IIN' Og MASTIUNs 0 00•
BUILDINGA DRE55: ` � - +
/ I 1 SANI'I'ARYNO. APPLICATION SUBMITTAL DATE
OWN(R'S NA 6:
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ARCHITECT/L•NGINF.f:R (YY�✓V {� \\// / \\\Y f1ULgI�G.1'CRh11T11NF0
2 On,9 Z LICENSED CONTRACTOR'S DECLARATION ,
0,_ I hereby affirm that I w licensed order provisions of Chapter 9(comorcndng _ Job Description
H a_+t with Satwn]000)o(Division3pfNa Busincasaod Rpfsipm Cpdc.WmYlicenee is a�9fT '.VJkW A"C i,-"N (2>1 -t- ere(7
k in full tmcea,eRecs. fY/VV
na0 License Cho - Lic,# '
s Date Crommr JM� ASD �I.��,th5 Pi�P v
C u.O ARCHO'ECTS DECLARATION
< I undmataM sh
my plans ell bo used as public menrdv -
ii
10 Licaoed Professional
OWN -BUR.DER DECLARATION -
h]< 1 hereby eRrm Nn I on,exempt from Ne Concretions License Lew for the
ne D following reason.(Saturn]031.5.Business W Profanation,Cade:Any city R county
onC which squires a perosis be cmuuucl,ahs.Improve.demdlsh,or repair my structures,
3= priormit,Tammce,dsomoons she applicant forsuchPrndttoneasig�statement N , +�q. Ft. Floor Area Valuation
Nn he is licensed pursuant in the provisions of the Conmmtorm License Law(Chapter 9
ton,hers exempt
and de,basis for th singed
Rue asmipliam Any who..of - APN Number Occu anC ,Type
Nat he 313 b therefrom e,Ne burs for be alleged<umpnio.Any it who..of � 02� 1� p y
Section then by my applicant for n Permit de applicant s e civil Prwry of
t mored m fere hundred ripa ddiart(5500).
.at pwma pf the PraRrty,m myemPlayesa with oyes n Heir role aamRns+tipn. Required Inspections
sol d0 the work,and the morns is rot intended cooffered for We(Set.]0f0.Business
and professions Code:The Contractor's License Taw does not apply to an owner of - -
tempmy,who builds or improves commit.and who does such work himself or through
his own employs,Provided Nu such impms"it w ere no intended ar pled.,for
alner-thowever,use Wil dingori rs of prmemuaddwithin onsysafm improve
doe
ownmboilda will have oW DUNen of Proving that W did not Wild or improve for Pur-
❑1,as owner eof pNe property,am exclusively and contracting with licensed attrition m
mod the es not (Sec.apply n an owner
of and property
who Wi Code:)The Contractor's and
whs couU.
cause w does mch mi.. ish.ofpromid'wca Wilds or improves Contra,md -
wicense sets for such ptojceu wiNaconuaaoor(s)Iz<na,purtuemmNe Contractors (/
License Law. 1
❑lam dump under S. .B&PCfor this ream
Owner Deu pO \r%O
WOR O ENSATI NDECLARATION /
Ihereby affirm r
Rpenalty of perjury one pfthe fallowing declarations:
I have and will mountains Cmifiesrc of Cosenuu self-insure for Worker's Compen--
asion,es provided for by Section 37M of Ne LaWr Code.for the perf amarc<of the '
work for which this permit is issued.
❑1 have and will maintain Wohena Competition lnsu.uwe,u squired by Section
3700 oft,Labor Cade,for Ne Rr(onnams of tW work for which Nis permit is issued.
MY Workers Compensation Insurance curia and Policy number art: ,
Center: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - �
into session mail not be,completed ifthe panus is farons hundred dollen 15100) -
rrl<ss.)
employ
my Person
in my
Newmkfor which Nim Pensonisin'Co oml
no employ of Rtion in my manor mo as m become subject she Wortrn'Compen-
sationLaws ofCalifornia.Dow
� Applicant •• ..
NOTICE TO APPUCANT:If,after making this Certificate of Exemption,you should
become subject to the Workefs Compensation provisions of the labor Code.you most 1
forthwith comply with such Provisions in this Permit silt W deem,revoked. -
CONSTRUCTION LENDING AGENCY
p I hereby affirm Nn them is a mnnroctlon lending agency far the,perfomwee of - -
Ne work for which this Permit is issued(Sec 3097,Civ.C.)
E. lenders Name
IX > lenders Address
W 0 ' I certify that 1 have re,this application and sus Nat fa above informants is
eeeq,,, sea,l agree to comply with all city and county ordinances and stoic laws totaling in
U O building construction,and hereby amWrioc rcDreaenutives of this city m sur upon Ne + ,
abovcoemion,Property for inspection purposes.
tge E" (We)agree m save,indem i(y aod keep homeless the City of Cummitro against
0 C.1 liabilities,judgmema,craw and .pcnsae which may in my way accrue agid taid City
W in conmque=of sW granting of this Permit. r
_ APPLICANT UNDERSTANDS AND WI I.I.COMPLY WITH ALL NON.MI NT
U z SOOUUR/TCZJC/RREEtGGUULLA�•T•/I/(]NS <Tf 00
.
r SigMurt of Applt VCont atm' I Da.e
NAZA DOUS ATERIALS DISCLOSURE
Will theeCupensor fucose Municipal
Cigle,Chaptmmor handle Hands and aterialSafety It 'O s
C defined by the Cupertino Municipal Code.Chapter 9.12,sod the HesIN and Safety '
cede,s«hen zs532(ii)] Type of Roof
C]Yea
Will the applicant.rfwort building acupmt use equipmenror devices which All roofs shall be inspected prior to any roofing material being
'i hsardou air commented;u refsned by the Bay Ase Air Quality Management installed. If a roof is Installed without first obtaining an inspection
imitio Y<s - ' �iTft I agree to remove all new materials for inspection. Applicant ,
I have read then contents,Pr
ardous conteieomsedL,
Pen aPra#.95af the Cash- understands and will comply with all non point source regulations.
fomes Health&Safety Cade,Sectioru 25505,25533 and 25530.1 understood Nat if oM t.
Wilding ds nor cuam0y have elenmh that It is my responsibility mnorify Ne=upms
1 N l whi on W a prior ser in, ree of a Certificate of vuR�nryO. '
Ler Y�T I a Signature of Applicant Date
rr o' m yen Date
All roof coverings to be Class','B!'or better
` OFFICE