00020191 CITY OF CUPERTINO_ - '',' wpm .. p ♦-m 5.i" - - PERMrrNO. - r
.BUILDING DIVISION; PERMIT , . CONTRACTOR INIFORMATTO1N% boo 6b
BUILDING ADDRESS - 4
SANITARY NO. APPLICATION SnUBM AL DATE
OWNER'S NAME: ,,••
WC CONTROL# .
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RCI II'fF,CT/ENGINEER "' + •'
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R'S DECLARATION LICENSED ID CONnsed unO w
p , y"' hereby affirm door am,fre8monstpmvlsrf of Chapter9(commenem8 w - .r, Job Description
rr with Savon1000) fD' r o 3 fth Busirmexand teem scads,arW mY L<e • •'
Yeamhalt rteeaneeRe :a!✓//ZG .. T,�C/JG�, NC3`^-/
License Cie s Lin M
.Date - Con vaz1 ! - '
p J ARCHITECTS DECLCL ARATION -
f y •1 understand m s shell be uric u public tecadx .r^ ✓p g,,y��� d'
a i taccnsed Ro(easmnal
..
OWNER BUBAER DECLARATION 6
C G 16me y affsm that I am erupts theContemner es n city w f the ', -`v /O O.
O foll - g rte (S cs 4031 5 Business and Professions Cade Any city a county
w as z ,wh' h requires a Permit in customer,altar,improve,demolrah,or repair any am -'Sq.tore - d ,
pit m't . senna v �reQ 'k:weappi troraarhpemuimmeaaigmaatakmen, cFtFloorArea Valuation
"wt he is licensed pursuant m Ne p aimm,of Ne Contractors Licenselaw(CTtapkr9 51 ,1' '} ✓t _ -
;(coiiumm�ng with Section 1000)of Dinaion3 of Ne Bunnms and Profes nxcadr)ar ' APN Number > Occupancy Type '
that he is exempt therefrom and w basis for the alleged as pt Any viaiNan ar P . Y. Yp
.Section 10315 by any applicant for a point subjectsthe applicant to e civil penalty ( z,� so:(
D O 3
t more thea five huiurrA dollars(S500).
❑I,as ownerofwproperty or my employ thwegesnthei ea1e aP tr 'Required Inspections., a
will do the work,and the structure is not hmendaloroRerrd foraale(Sa:4044.Business
i
end Propesaiom Cade The Conmctprs Lrttnse Law does ma aapply to an owner of i r'1• i 4r*
propmy who builds or removes thereon,and who does inch work himself or through
•his own employees,Provided that each imPmvemenu are not miumad m otherad for
We.If,Wase,thebuilding orimpmvemenus sold within aneyearefcompleuogw
mvau-imldrr will have the buNen of proving that he did not build in improve fm Pur < • ^' t
pose fel ) 1t ' F •e ,
1 f the property,em exclusively u ung with licensed contractors,to • ro, ,
consumer the p jai(S T)44 B mness tau Professions Cude:)DTe Contractors W
cense Li dais rail apply to an owner of property who builds or improves human,aM pbf i
who contracts for such projects with acanvactor(s)Reused pursuantmthe Canvecmr
License law - - - ( '. "
❑Lam cxemP rtes Sec. BAPCformisreaq A { -
...Owner Date02 Q$-o0
WORKER'S COMPENS ON DECLARATION
i erebY affimn under penalty of perjury one of the following d lam i b h
�❑ n. its 'll far
etism37u of me Labor self,f the
Works aCo of
ny , i
Won. pro dhi fa by Sauan 3100 of the Labor Code,to Ne perfotmarice f th i s
wo[Ir for whim this peimrt rs issued.
❑1 have end will m Code,outin
Workers Compensation w rk for which
h required by Section
•r
3W0ofw Labor Codeforwuranc caro and work for this permit is issued d -
My,Workers Compensation Insurance comer and Policy number arc: -
` Cerner. Policy No,: s '
CERTIFTCATEOFEXEMPfIONFROM WORKERS -
' COMPENSATION INSURANCE •-
i (This¢cnonnee not be crra'at hfthe pertn lin foronehurdrdl dollars($100) _ t .t - '
or less.) ' i v -
"s i. Iterify itir aperform"ofma work for which this permit is issued,l shall
not employ any any manner max m subject to the Workers Compcn-
ration Laws of I n e
APPhcant i - w
.NOTICE APPLICA .If,after ma i g Centficete of Esempuon you should . t' T ^
hccomc stabled to the Workers Compenuvon provisions of He Labor Cade,you mor '': - '•4�
forthwith comply wit such provisions or the pewhshall W domed revoked a 'tea e, s
z tG -1 CONSI'RUCIDON LENDING AGENCY ,+ -.,,, "' •C +,
,.0Q I hereby affirm that there sa construction lending agency for the komum f.
#r' the work for which thispgEn t x issued El 3091,Civ.C.)
t„a Lenders Name `
�. ,lenders Address - a
gW 1 unify Nat I have read rue aPPI. tion and sale that theabove nformer
Gr'Q conem 1 agree m comply with all
city and county molmonces and sur larefining t ..
Z '•building construction.and hereby audam representatives of thiscity to emer opo w '
U' above mentioned Pmpcny for inspection Purposes . '
• W Fy .(We)agree totie mdemndy and map hawless the City of C per om itnmst
QV liabtites judgmen costs and expenses which may in any waycconagmnat se dCty, Aid -ad �` i
consequence bunting of this pemnir. .. i - -
[ti �+ .APPLICANT DERSTANDS ILL COMPLY WITH ALL NON-POINT
V ti SOURCE: .UI AT
aZ
i •Si reofAPPlicanJCo Date
-HAZARDOUS MATERIALS DISCLOSURE
Will the applicanto f rare Wilding Occupant store or handle hazardous metenal' Re-roofs '
as turned by the Cupertino Mumapal'Code Chapter 912 arta the Health and Safety +5' • oC
_ Code Section M532(a) _ Type of Roof
❑Yes' s . 1n No
Will dm apPbean[or future buildingocc pent'use equipment or devices shch •:,All"roofs shall.be inspected prior touan yi•roofing material being` '
emu hazardous air contaminants as defined by the Bay Arra Air Quality Management installed. If a',roof Is installed without first obtaining an inspection
fi-nil' 1,aqree to remove all new materials for'inspection. Applicant
' .Dyes ,. .f �No.•. '� .. ' . 1 go
lhave whaardousmaterial ialuremenisuiucrChaper695ofthcCua Bndersfands and'will comply with all non point source regulations.
forme Health Safety Cade'Swtions 25505,25533 and 25534:1 understand thefif the ' - -
buildingda not current' sane.[door it my responsibility m notify the Dompant
.of thele menu be riot pnon isanceof.Cmifiwteof Occupancy
rt
- C2— _o Signature of.Applicant • len. Datg�. '
or cut Tori a Bent ':Dau a• •:A;. a
" ' - - •'
All roof,coverings to be Class"B' or better •'
"J OFFIdE