00020163 - CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: O0 4,2, p /' G 3
N �xA yy text) Q SANITARY NO. APPLICATION SUBMITTAL DATE
0 T CONTROL#
RCIIITECf/ENGINEF,R - HOLDING I'I;RMII'INPO
;kap - 197- b% 6 .
LICENSED CONTRACTOR'S DECLARATION' ' •
Z 0 w— 1 hertbY atTimi Nu 1 am licensed wider ryovisions of C 9 mmehrin
o<= hepter (� g Job Description
t-=FW with SecrceandejecD;vi.ion3af NeBuaimuand ProfeasioKCade,and myliceou is "
�yS�Q In(YII Ione end CRaL ., //�T �f)1 f,�t�
d Licenne Clan, ' B Lia.«' bS o 3 a y AP I`s \G.. •..•. 'Il f' . -D-�' r A W"t�
i 3 h Comsat., N �'a'N•` 00`wC.�)aw ^" �`,� _ -
F:O ITE S DECLARATION �' Ate Cb-LO f-r7s�rt'�
j, 1 pl s u blic rccuN '
o o .tQ�v
o LI sed Pmfers oKl ..
OWNEon exempt
tfrmthe DECLARATION a/JT n� �
C<G - 1 hereby;Kum thatOW 1 R-exempt from the RA ION License law for irks K Q// //r.•�'
2H O following mason.(Section]03 L5.Business and profession;Cede:Any city or county te.
i 3 w which RpAres a permit m construct,alter,improve,demolish,or repair any auuclurc ' S F[,.PIOOr Area)pdono......dao sequin;the applicant for such pmdt to 6l...igmatimemcm - ,q• Valuation
Nm he is licensed pursum,to Ne provisions of the Co..,&.U.nm Le.(Chapter 9
(commencing with Section,7M)of Division]ofthe Business and li fossioK Cade)or
that be is exempt therefrom and he basis for the allegedeaemptin i Any violation of APN Number Occupancy Type -
Sm ion]031.3 by any applicant for a permit subjects the applicant to a civil penalty of 3 6' /1�1 -�00 Q .,
nm mom Nan five hundred dollars(SLID). V_3 V V '
❑I,a;owner arNe pmpetr.w my emplayR.with w.ges m Heir sole aampeKWan, -Required Inspections
will do Ne work,and Neem is not imendeJ proffered fwsme(Sec.7W.Buaineu ,
and Professin",Code:no Common'License law does not apply to m owns,of
property who builds or improve.me...and who doe.such work himulf w through -
his awn employeca,provided Nu such improvements are not intended or offered for
cars.If.howea will
Wil ding,improvement is sold did nonsild rfmmple for the
ownrnbuildtt will have Ne burden of proviry that he did not build or improve f&ped-
you of s .), ^ t
I ow
son
u ow f the Ser.7property,.1 e1buts. Iy Mooching Cod Iucn.M cnnvadnn to . .
U.
verse I.A.N es mo ISa IMG,weer of
rd Prof colons Code)The Conhacton,and!Genu Vd«. t apply to an owner of property W Wilds w improves tvaeon,W -
Licm Law. ouch prolecuwM aanmutarOlicensed punuenlm Ne ContncmJa - �`/
❑Ism exempt under Sm. .Bk PCfw Nu mount • " �''
Owner Dau
WORKER'S COMPENSATION DECLARATION
_ 1 hereby.111 under penalty of perjury orR of the following dedamtioK: h -
evx ponsu li for by
a tim,37W of Co Labor ul6insuse she
Worke,Y m of fire
m provided f e mi Salon l]00 of the tabor Code.for Ne pedormana of the - , -
rk have
which ill permitissued. r
❑1 nave end will maintain for Worker.Corm oOl ton work
for hi h requited by Section
3](pof the4Wr Code,for the perfarmentt of Ne wwk for which this p<m,is is iaauW. -
My Wor s Compensation In;urantt carrier and policy
cmrien lS�Z1JiDS Policy No.-a{1Y
CERTIFICATE OF MEMP'NON FROM WORKERS' -
COMPENSATION INSURANCE '
(This section need not he completed dihc pemhit is for one hundred&Ji m(S 100) ti
I certify that in the performance of the work for which this permit is iuvat I shell
not emplo ny person;n any mmsc w m bee R antRe,m the Worker'Compcn-
tminn fCafifmr I
Applicant
NOTICE TO APPLICANT:If.eirlossm,Ni.Certificate of Exemption.you should
hecome subjal to the Workor's Compensation provisions of the Labor Code,you must
fomwith comply wit such provisions or this permit shall be deemed mvokW.
z .N , ,. r
CONum is a CION LENDING AGENCY
Q k far which m rise mimorch i issue(Sm.]Knlending agency for the performance of
r the work bar which Nis pelmet is issued(Sec.J09],Civ.CJ _ e
Lender;Name r
B] 1 cenify o 1 have Rad Nis y and coup and sum tut the above w.rclum,is - •.
Z. building I agree,to comply with ml city and county ndmis ncef and sum laws r upin t to
Z eov.-goramed i., oyM1embyaathoriutposes. tivK of this city menu,upon the '
uMvc.(Weia agree
property for inspection keeps
4 E. (We)agreeRcove,indemnifyand keep hem dem mewCityof Cupertino said City
V incm..m;u.rcof tis,court and ex pen pe which may in my wey.ameegdnst coed City
w W inconxqua<e of irks grunting of Wa permit,
'LICAN"I'UNDERSTAN AND VI-LCOMPLY WITH ALLN(1N-PO1N'I-
f -
t, z .,OURCE REGUI 0 S. v - -
- �J 'SigTillm, o6 8g ofApphcenJComm�or � Dam ��'
will R r.p.HAZARDOUS MATERIALS DISCLOSURE,
plicantorf Lute Wilding occupanumre.,handle huu errs material Re-roofs -
u defitud by the Cupertino Munic es
I Code.Chapter 9.12, t the Health and Safety '
Cade;Section Z532(a)] - Type of Roof
D Ves No
Will Ne appliant arfumrc building«;pant ergs wuipment or devices which All roofs shall be inspected prior to_T roofing material being
amtmmolonneirennwn�dxfimdbrNeR.yAn.Ai,GaailyMam,sn-m " installed. If a roof is installed without first obtaining an inspection
�']
El Yes [I No l a ree to remove all new materials for inspection. Applicant
Iluvc Rtl the hexuduue tnatrnm. pmr 695 of the Cdi- un erstands and will complyRgnijementa aMcrGM with all rion point source regulations.
furn
is Health R Sefely Cade,Sections 25503,25333 2553G.1 understand Nat;f Ne• -
dingdoesnoteuneml heti aline in, myrc vbility to nwify Ne wcupant
Nc reprinemenuwm mol tprior ni em of Qnupency. •
G n o .;Non antSignature of Applicant Date
"' I
Date
All roof coverings to be"Class"B"or better
OFFICE`.