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00020062{ CITY OF CUPERTINO - BUILDING ]DIVISION PERMIT CONTRACTOR INFORMATION: BIJILDING ADDRESS: 0002 (p Z_ 3t- •PNON./ 'yam .� -O _ - _ ❑ ^ _ ARCHITTEEICT /HNGTNEER t' BULDING PERMIIANFO ^T MccZ ya LICENSED CONTRACIVR'S DECLARATION " • O vvi I hemby .M. Net I am licensed order provisions of 9 commeain o z — Chapter ( g � � Job Description m�5 with Section L0d0)ocDivisionJoftW Bminusad professions Code,aM my licanxis in full force and effect - - s 1lzena Class Lin. N ��� ,,v �� ni 3 u N Dam Contract, s DELL /J_`If - ,� ARCHITECTS DECLARATION '� � j, � 1 undamad my plane shell W used u Public acOds _ ' , Incmxd professional IuS 1 OWNER -BUILDER DECLARATION 2C Q I hereby .(Sere that 1 un exempt from to contractors ou License Lew fa the Q following rtamn. (Section cons 5, Bueinecs and improve. dO professors Cale: Any city or county i-o • -6 3CCC3 which rtquisa a permil m construct, alter, isrywve, demolish. or rtryir any suucmre S FL Ftoor Area • - pooru its issuance, also cultures the applicant for pemdtm file uigned atvcmmt q' SvadU O� Nm he is licenod vunuanuo the provisions of Ne COnvadota Limnse Lew (Chapter 9 (commencing wit Section 1000) of Division 3 of the Beaineu and Profesdana Code) a No he is exempt therefrom and The basis for to megd exemption. Any tiuleaon ar .-3 - APN Number a OccupAcy 'Type . Section 7031.5 by any applicant far a permit subjects doe Wheam 10 a civil promo ty of ©© , not mom Nu five hundred dollars (5300). - JJJ ❑ I,. as wnaof me, proicamy employees wit w .gesas dicrrolacompenuaan, .Required Inspections wlll do Ne work, end NeeWCturc is tmtintendd oroflerd for We(Sec.1069, BYllKS, and Prek,si is Cale: The Contactor'. Liana Lew doei ma apply to an owner of Ptolemy who built Or improves Lemon. W who don such work himself at through • In own <mploy.a. provided to such improvements ax nor intended or oftertd for aide. IL however doe Wilding m improvement la sold witinane yearafcomphrim, to �ow lder will here Nc burden of proving dolt he did mat Wild or improve for pur- Wa wner of the property, atn exclusively contacting wit licensed convectors to - s e pm sal (Sec. 7(i66, Bmineu and Profession. Code:) The Cmurac or's U. - tense raw dins not ply to an owner of Property wW Wilds or improve thereon. and - - - whoconrrea Licarse rojects wiN econuator (allkenxd Wrsuantm Ne COnvaiots _ _ __ __ ❑lam em r ac ,BRP f �n ( /IV /C/ ' Owner Thu WORKER'S COMPENSATION DECLARATION - . have artbyelfimrtain a penalty of e perjury max ofteimurcur Worturs Co: ❑.m.. and will for maintain OfComent 10 LaborCde.forIn, rfoormce ofm cation. r which pe ne Section 3100 of Ne tabor Cale, for to peAomuna of me work for which will narrate is issued edxe - ❑ I lute and will ore, for oorkds continuation of w Insurance, o hisuiaa by Second My 37W.f Watr's Co Compensation to Dann,( docwprk for numbir am: permit is leaned, - My WakeYS Compchution lnatraac carder policy number era: Gm¢ Polity MOM OF SACIONIINN FROM WORKERS' COMPENSATION INSURANCE — I (Thine union nee, nor Wcom0lerdiftla permit is forone hundred dollen (4100> or less) I certify that in te pehON.,&Ne weak for which his pom sued it is is, I shill not employ any tenon In any roan., an u m secure, unnect TO doe Worker( Co.,.- - - ' action laws Of California. Dane Applicant r NOTICE TO APPLICANT: If. after melting This Certificate of Esempaon. you shouts - become, subject to doe Workers Compenution provisions of the labor Code, you mum ` fonhwido comply with such provisions or Nis permit Nall ba dared revoked! .. : CONSTRUCTION LENDING AGENCY t (• Q I hereby affum OUt tea isaco... Gaon list IT yNxdor parfumuaeof Z the work for which tie permit is Salt' ( a. 3091, Civ, C.) E: Lenders Name Q! ii UsideYSAddass_ [r7 0 1 cenifY out 1 have rtd t s and ewe don the above information is - %)+ career. l egrte to comply with dl it ou y oNinanue ad euu laws.toting to - U Qbuilding conewdon. anJ hemby utho zcapaunwivesofthiscitytocm, 1. onthe abovememwnd proany for no,axI an puW.,. ,r W E.r (Wc) agree m eve, indemnify and kecp Mmrless dot City o(Cupenino egdnst 0 U Iiebiliies, judgments, costs and expenxs which may in any wey.ecmeagdms mid City W m emaequ<nce of the granting of Nis permit . - APPLICANTUNDERSPANDSAND WILL COM PI.Y WITH ALL NON -W)INT ` SOURCE REGULATIONS. Signatme fArplicandCamnct., Dora �o - ,,,7o v , 3359• HAZARDOUS MATERIALS DISCLOSURE . Will Neapplicutt or future Wilding acupant store w handle hazsNOUS mevid Re -roofs as defined by the Cupcm 0 Muni I Cde. Chnptsr 9.12, eel she INN and Wary cod ex x3s3mn Type of Roof ' ❑vane No � ' - .'., WII Ne applicant err ma Staling acupant use equipment or devices which All roofs shall be inspected prior to anyy roofing material being croft hamrdoua air conumin ts de End by the Bey Arce Air Quality Management installed. If a roof is installed' without first obtaining an inspection . D``tiC1 I agree to remove' all new materials for inspection. Applicant �Ye der maudd. uiaments under Chapter 695afdteCah. understands and will comply with all non point source regulations. - fomu Huldo�S fat ` Sections 1$6U 25533 and ]5336. 1 much tend that if the building d 'y heveeannn 1(ot my ptnsihilitYmry�(,J(fY t�o acuvant x of the alai n MMxLf. iAe['mifirnr(XfVr.•te...n 1 t�_t/, x- Y Signature of Applicant - uroretflhefz agent Dae All roof coverings to be CI OFFICE Date "B•" or better i