00040040 CITY OF CUPERTINO - PERMIT NO.
BUILDING DIVISION - PERMIT BOO NTRACTOR INFORI ATIO ,�� �`fOOS�O
BUILDING ADDRESS: r - -
•/� SANITARY NO. APPLICATION SUBMITTAL DATE
NIC - ' CONTROL#
II 1 r 1
RCHI'ECTICNGINEER - "' BgLffING,PERMITIINF,b
0C
FLICENSED CONTRACT'OR'S DECLARATION
o°z ihercby.Ir�,nN,tl.mEnmer pmvi.io�nf chaptn9(enmmeMing Job Description
a— with Section]000).Htnvidms Sotdafimmensand Profead..Cade.and my license is
in full force and effect.
License clan Lic.#
a y Deo - Connector '
(_i O a ARCPB=S DECLARATION
a 1 understand m"Baseball he used a public hmotdi
cz Licensed Professional
OWNER-BUR.DER DECLARATION
I_Z 1 Worley affirm that I am exempt form Ne Contractee.License Law for the ,
I pfollowing reaaan.(Secure 7031.5,Broin..end ProBtea is Code:Any city ornately
which requires a permit to construct,alter,improve,demolish,or repair any sNrmm 3q:Ft.Floor Area Valuation
prim to its isuana.abo rail the applicant for.uch permit to files signWt ettaccu -
.that he is licensed punuanr rc the porvisiom rfthe Cannano's License Law(Caspar 9 a,'Z,ry f�✓
(commercial wish Sa9on 7")of Division 3 of the Bmineav indl'rofesw.....0 'ler A Number
m✓e •f��
that he is exempt therefrom and the basis for Ne alleged exemption Any violation of Occupancy y T)pe
Section 70313 by any applicam for a permit subjau the applicam to..isil penally of j
Irel mor'dean five hunted dollara(3500).
I,u owner of Ne#ropey,or my employees with wages u their sole competsetior. Required Inspections
l doth'wosk,end Ne ewcmrc is tat inrctidcdaraRcred(male(Sec.]044,Business _
and Professions Code:.The Contractor's Li..law does era apply m an owner of -
poparty who builds or improves thereon and who dm such wart himself or through - t
his own employees,provided that such improvements me era intended or offered for -
sale.If,however,the bulldiati m improvement is sold within one yearofcampution.the
ncr-builder will have the burden of proving that ba did nut build or improve for For. -
pose of sae.). •.
❑1.as owner of But property,am'.eluaivcly contracting wide licensed Contractor to
camnuct the project(Sec.1W4,Business and Professions Cade:)The Connor's li-
cense Law does hot apply to an owner of property who Wilds or impravas thereon,and
who contracts for each projects with aconuecmrR)liceniedpunuam tO Ne COMecmr'., -Lion.La..e
❑lam<. rade See. B&PCfor Nisonarota '
Owner /AAI f g1 I Dae
WORKER'S COM AT ON DECLARATION
i hmeby aRrm undo pmWy of perjury one of the frllowin{dcclaratiots:
❑I e.as end provided
or by Sects.
37 rt ofComrnuo se d imur the Woder'r Cumpan- - '
waion,as hick hi for mi gs isa n 3100 of da Labor Cade,for the per(omunee of rhe
wok for which ills parotin is issued.
I have and will maintain hepeffWinters Compensation weak
far which
a acquired by Batton -
MyWorNclabtCadeforthsurancecanee athcwork forwhich Nis pumit is Words I
Co pander's Comprnutian Insurance coma end Policy vumber tee: - V
Cemee- Policy
CERTIFICATE OF EXEMPTION FROM WORKERS' - -
COMPENSATION INSURANCE
(This.anion toed era be romplerctl join,permit ie for one hundrnd dollen(S 100) �•1
or Ica'.)
I employ
ify met peers to the pertomareC M s to become
for which this pmth is issued, eau- O
shall
no employ dry Corson inmymanner so as m became nubjana the Woken'Compeer-
setioictent of California.Data
Applicant
NOTICE uh APPLICANT:If,atom making this Certificate of Labor od you should '
baotne ccomp to it Wodrcr's Compensation'tune Provisions of the Labor Code,you must.
forthwith comply with such provision a this#'mitt shall be dcetihd revoked. -
CONSTRUCTION LENDING AGENCY'
�'� I hereby Nen Na Nem is econvwcuon lending agency for perfurmmce of .,
Z
the work for which this permit is issued(Ste.3097,Civ.C.) v
E. C4 LeadrJs Name '
C. > lender's Address
W; I unify Nat 1 have read Nis npph.Ii6n end arae Nat the above information is
L Q .cornet.I agree to comply with all city and county ordinances and ass laws relating to - -
IDO Wilding comtmcuon,and hereby authorise represenutiv's of thisdty to enter upon Ne -
id eveed pinspection
-munumnopery for pureasea.
W Fa (We)alta 1.....indemnify end keep berrnleu the City of Calamine against .
V liabilities,judgments,cods and expenses which may in any way acme against aid City
�a W in consequence of the granting of this permit. n
F_ A. APPLICr1NT UNDERSTANDS AND WI I.I.COMPLY WITH ALL NON-PRINT
SDO E EGUTATIO S. ``
U � AO��/1'6— T//dV d
Signuurcuf ApplicaniContractor• - Data
KATARDOUS IAIS DISCLOSURE
Will the applicant or future Wilding occupiers store or handle haradous material Re-roofs
as defined by the Cousin.Municipal Cade Chapter 9.12,and the Hcu19b and Safety '
Code.Section 25532(07 Type of Roof
ClY. VS. ..
Will the applicant or future building occupant use equipment ser devices which All roofs shall be inspected prior to any roofing material being
but hanardous sur conaminuarta as deffined by the Bay Area Air Quality Management, installed. If a roof is installed without first obtaining an inspection
nudist?❑Yes es I agree'to remove all new materials-for inspection. Applicant
l\ d
(have red the haraNmeo
uus rials rcquirtments under Chapter 6.95 of Ne Cali un erstands and will comply with all non point source regulations.
a
torose Health&Safety Code,Sections 25505,25333 and 25534.1 understand!that If the
/da -
f
the gdou era curren0y haveatmant.Ntir is mY rtrpomibiliry mnmifY theoccupant
' a rtquir\nmp�P must be ran pias uauenee f e Cen�no ssf Oaupanry.
\/ � s3 e 7 _ Signature of Applicant - "Date
X Ownermauth nt.., + Veto - e
All roof coverings to be Class"B"or better
�`'a �.��° —•�. OFFICE p — a. ��✓ L!^-Z