00030175CITY OF CUPERTINO
- PERMITNO.
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:,
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BUILDING ADDRESS:
SANI'1'ANVNO.
APPLICATION SUBMITTAL DATE'
/O� s ✓/+R+N^ryGA 11D'`
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OWNER-SNAME;
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BrJLDING PEHMI"f INFO
ARCNITECIYENGINEERER - -
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LICENSED CONTRACTOR'S DECLARATION
1 hereby aRron that l am licensed under p ovisou a of Chapter 9 (commencing
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withlfume9o00)of Diviaiod3ofthe Business and Pmfe.ioou Code,and mylieemeis
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Li«e a..nasu Dal< Contractor
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ARCNI S DECLARATION
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1 understand my pliryslWl be uvd ss public rtc«da
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OWNER-B ER DECLARATION
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1 hereby affirm that l sur esempl from Nc Contractors Lima. Law, for the
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following (Section 9031.5, Business and Professions Cud: Any city or county
Sq. F!,-Floor Area SPS
Valuation
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which mqunea a permit m construct, altar, improve, demolish, or repur any moment,
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t print to its issuance, also resorts the applicant for such permit file a signed statement
thatheisll«naedpunuantto Nepmvisionsnfthe Cmaulnea License Law(CMpter9
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(commencing with Section 7")of Division 3 of the Business and Profnsians Codcj«
that M is therefrom the bssis for the Any
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Occupancy Type
carmpt and nllegM exemption. violmon of
Section 9031.5 by any applicant for 0 paneh robjecta the grylicast to a civil Penalty of
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not assume Nen rive hundred dollars (3500).
I,uaw«r of the prapeny. or my employswith wages u Ncirsciccompewtim,
- - Required Inspections '
will do Is"od, and the slmcmrt is net intended or offered for aid. IS., 7044, Nuunna'
and Prof.dons Cade' The Connacmr, s License las does not apply to ..a, of
property who builds or irdmves thereon, and who dos such work himself carthrough
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his we cmployaca, Provided Nu such improvements are not intended or offered for
improvement it s ossa Yev of romplelion, Nc
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marn'thoweveL
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Kr-bu1Mtt will hsve she burden Of proving Ihnt he did n01 bulltl ar improve fed pec-
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of sale.).
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L u of the Property [m eaclucivclY eontrcdn8 with licensed conlrectms m
wart the (S«. 7W, Business Professions Cade:) The Contractors Li-
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project td
cense law dace not apply to an awn. of property who builds or improves thereon, and
who commasfor ty tm
projects with a conatoe(s) licensed pursuant to the Contracires
License Law. . • . '
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❑ lamexem .B& PP C for this resom
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Date
4WORKER'S COMPENSATION DECLARATION
1 1 r0irm under penalty of perjury otic of this following decimations:
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F1 have and will maintainsCertificate ofCcoman to self-insure for Workers Compen-
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nation, as provided for by Section 37M of the Labor Code, for the performance of the
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work for whlclathla pemtir is issued.' - I ' 1
❑ 1 have and will maintain Worters Compensation Imturnme, as required by Section
. 3900o1' the Labor Code. fnttirc prrformeosueclone it for which this permit is issued.
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My Workera Compensation Insurance... road Policy number are:carrier
Policy No.:CERTIFICATE
OF EXEMPTION FROM WORKERS'COMPENSATION
INSURANCE'07h
ssectionneednmbecomPlerediflhepermitisforonehuMWdollar(5100)orl.
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In Ne pertoronence nfthe work r«wMan Ni.pemir is issaedI shall
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not employ any person in any manner so as to become Whims to the Workeri Cooper.,
salion laws of California. DaleApplicant
NOTWE�TOAPPLICANT:�
. become subject o the Workers Compensation provisions of the Labor Cade, You most
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: fmthwirh comply with such Provisions or this Permit shall be deemed rwoked.
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CONSTRUCON LENDING AGENCY.
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enry forthe perfomwce of
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the work whichsNpFamousgluatre is (Sm. , Cd v CagJ
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Leaders Name
Lander's Adds.I
and sura WI the above sus mudon is
Knee Nor 1 have recd Maty
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wallcoup missing
comet 1 agree c comply with all city and county endurancesof tris eine laws
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buildingcmm�edpro and herehspectonaereoses. Lives of this city memer upon the
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above mentioned for map«tion purposes
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e,ju agree to uve indemnify and keep harmless the Gly ofe,mo, sCupernmet id inst
liabolities JWgmenls costa and expensev wM1UM1 rnay'nanY waY accrue egmnsl said City
City
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in consequence W Bran g of this permit.
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APPLICANT ANUSANU WILL COMPLY WITH ALI,NON-PoINT
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HAZARDOUS MATERIALS DISCLOSURG
Re-roofs , -
WillyteCupertnofMuni bpalioade. Chapt vote« hal hammounmatend
aa defiKd by the Cupertino Municipal Code. Chapter 9.12. tad the Nee1N and Safety
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cnacYc15532(a)?15532(a)?� / �
Type of Roof
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" wiathe.pplicant«rima'ebuildin,M=apant use equipment or devices which
All roofs shall be inspected prior to an roofing, material'being
' installed. If
mith.!=..ir«numiunbaxde nedbyrM1eBayA a An Duality Management
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a roof is-installed, first obtamin'g'an inspection
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I a nee to remove;all-new material's foi'inspection. Applicant.',
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Understands and will comply with all non point source regulations.
Ibve hazaMwanu¢dslamquiementsoM.Cheger6954thCI .
forma Health P§ifkfety Code, Sections 25505, 25573 and 25574. I understand Nat if the
building cloi,6014,ucready have a¢nen6 Na it is my msponsibiliy to nmify the«cupam
note wh hmust be tort poor to lssuarce ofeCertifcota of OccupeKy.
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Signature of Applicant. ` •' Date
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Ow onulhnnzed agent - ter
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All roof coverings to be Class "B" of better
OFFICE '',