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00030035 CITY OF CUPERTINO - PERMIT No. BUILDING BUII, ION PERMIT CONTRACTOR INFORMATION: ©o0 30 n SANIIARYNO. I APPLICATIJON S UBMITTAL DATE. V NER'SrEVE: / NIC CONONTROL» PH7> AS I L • - G-U .� I�li✓O IDA CIIO'ECI7HNGINE9 !� ��J� fll14DING 1'gRh1rT INFO F C vu� yzu F i LICENSED CONTRACTORS DECLARATION o z=o I hereby affirm Net 1 am licensed undo provisions of Chapter 9 my Imems,is Job Description P Fm to Nil Nrc:ad affect. ofthe Businasand Profession Code,and my learn is z ,.I in full force and eReci. Q License Chss Lic.» gy Date Convector //�� C O Q ARCHITECTS DECLARATION �w r S 1 understad my plans ahJl M used ss records corda 6 w O Licensed professional w`= OWNER-BUILDER DECLARATION Z�¢ 1 hereby affirm that I am exempt from fie Contractor's License Law for the �C following mason,(Section]03 1.5,Business and Professions Cuda:Any city or county m. w which requite a permit to construct,eller,improve,demoliN;or repair any swerve poortait,iesuaince,also"onestheapplicantfarinchpermittofilarid,iedstatement Sq.Ft. Floor Area Valuate - that he is licensed pursuant to the provisions of the Con.On'a License Law(Chapter9 � (mantendmg an Section]0)0)of Division3ofNe Business and Professions Codc)or APN Number that he is exempt thacfmm Occupancy and the basis for the alleged exemption.Any violation of /n/ P Y Type Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of of more Nan five hundred dollars($500). O pI,nawner of Ne pmpet,.nayempmyees wiN wages as their auto compenadon. Required Inspections will do Ne work,and do, tmcmm is not intended or offered for sale(Sec.]044,Business ane Profeulom Code:The Contractor's Latent law does not apply m an owner of properly who[trims Or improves drams,and who does such work himself or through his own employees,provided is.such improvements ate not intended or afford for sale.If,however,the building or improvement is sold within one yeuofcompledon,the mer-builder will have the burden of proving that he did not build or improve for pur- cott of selhJ. ❑I,a4 owner of the properly,sm exclusively convecting with licensed convectors to construct d project(gee.o an owner of and Profession Code:)The Contractors rid cense Law does not apply ro w owner of properly who builds m improve,Neeson,and who contracts for suchprojats wiN acontrecmr(s)lic<ned pursuammthe Contactors j License Law. ❑IamexcmP% a. ,BB:PCfor th' masun .� owner W R'. MP ATI NDECLARATfON �® fy 1 hereby alts oder penally< rjury one of the following decimations: C! OIhove and will maintaineCerificate of the Labor Code,fort for Worker's Comf the cation,as provided for by Section 3]BO of the Labor Code,for the pertormanm of the oh for d this permit is issue and. ❑I have and will on�.fon WOhor's Compensation w rkfor hie.h requires it i Seaton My othe Labor Cede,fur thepeRomlaro Of the work for aNig Cermet is esaud. My Worker's Compensation Insurance coma and Policy number art: Cartier: Policy CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This sadnn nttd not becompleted ifthe permit is forOro hundred dollars($100) ar less.) 1cenify Nalco the my onnuar of the work far san.hia permit isissued,Ishall not employ any Califon in my morns so as to become anbject to the Workers'Comfort. sminn Laws of California.Dam Applicant _ NOTICE TO APPLICANT:If,itis,making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you most L� b forthwith complywith such provisions orthis permit shd all be dearmsmokedaffirm NCONSTRUCTION LENDING AGENCY MAR 0 3 2000 Q I hereby affirm Nem is a constmedon lending egrwfo y nhe paforwaso of 2 NO work for which this permit is issued(Sec.3u W,Civ.C.) Under,Name a , lender,Address By — [yj 1 certify Nat I have read his it,billwn and sure Nal the above information is 7 z <otreet.l ogres[o comply with ell city ed county oNinnces ad sten laws relating m —'� building actioned pro end hereby inspection purposes. taziva of this citymenter upon the above-me o afire pmperty rind emnifyiA keep hs. kL iCy (We)agree m,ave,indemnify end kap harmless the City of Cuperlino send City W inconsequedeof the costs oil expenses which may in any way nccmeagainsl seiJ City '�. GT: inconsequence of the graining of this permit. I• APPLICANT UNDERSTANDS AND WILL CONVEY WITH ALL NON-POINT / »- SOU R�C FIAI IONS U '1' f v� �. T tom. Si azure ufA cant/ o taco D. 1��,3 H .RDOU$MATERIALS DISCLOSURE V / rl' 1 J1 „el Will applicamorfuturebuildingOccupantstoreorhandlehaaerdousmaterial Re-roofs as defined by the Cupertino Municipal four,Chapter 9.12,and the HcatM1 and Safety Code,$anon M532(a)p l Type of Roof Cl Yes Will the applicant or future building Occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being emit barardous air comemiuro'S3,gefined by the Bay Arm Air Quality Management installed. If a roof is Installed without first obtaining an inspection 7 ”" / I agree to remove all new materials for inspection. Applicant ❑Yea [�)i16 d (have red the M1anaduus materials requirements under Chapter 6,95 of the Cali- un erstands and will comply with all non point source regulations. mu Hwlth&Safety Cade,Sadons 25505,25533 end 25534.I udersmnd Net if the ildimg dor,not cudmmly M1nve a tenant Nat it is my rtxponsihility to notify the oecupant ofth smartsi�r� Us'be nett Cron ostaae of a Cerlificm<o Occupancy. . 7_ 3 11» Signature of Applicant Date flearelms7mad.vto All roof coverings to be Class"B"or better OFFICE