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00020071' . CITY OF CUPERTINO . -._ ` - _ - - PERMITNO.• . . BUILDINGDIVIS`6ti'. PERMIT +CONT,RACTORMORhtATION: "OOOZO 0 � I • BUILDING ADORESS Sec • �, Ui �s �J• �• -ks, SANITARY NO. - A SUBMI XA-tv APPLICATION TTAL ATE /r/ r 9' -'9.' ..., 'OWR'SN E: NIC 'CONTROLN PH NG. �� ` •^ . OO' ' ARCIIITECT2NGiNE/E�R� woo V. zf. 3 LICENSED CONTRACTORS DECLARATION o z I hereby afftrrn that 1 arn licensed under provisions of Chapter 9 buturneeming Job DescnptioB INSat 7(X)01 fD 3 afth.B.amen.andfiraft mm,Ccisla.and., hecomas. i 3 i re full force and effect 4 _ / o as uGGQU Lice CI Ltc dmmnd mY Plns sMI b u u Public rcs Det Comment A T T'SDECLARATON ne ' Awrp Oo X lac sail Profes,i.md ,• i.- (ni {� /� /r ,t���I -. v, ,v,'' OWNER - BUILDER DECLARATION • 1 ` ` `C. /�I \/ `•,:`F7� in G 1 herctiY affirm the, I am eaempt from Ne Comndofe L case Lew for the t zO follow g vas (Section 7031.5. St asnces mad Profesaons Cade AnY my m cou ty ' 2 a ' i 3 which rM sees Permit ui consume' ilnr improve, demolish, or,ePa"M Y awctur S' ''Ft. Floor Area Valuation ' . 'p t 1 e maanioreepmappbcantfmanchpeme .Li.lesatg dsh.pt ,r(t ^t q eft ` ax ©o O I thath 1 nwid Pu u 7 N pmvikonsnfthe CannecmisU a law (Cheple 9s .� v ,�. /`r /Y • (<otitmE 'ng 'NS cu 71X)p)of D' ston3 of Ne puniness and Prof ions Cad) ` that n mPt therefor- and the be is r : thE alleged exempu Any vmlahon of . .r • -' A NiNumber' - ,Occ alley. Type - Secu n 7031 5 by y.pph,.t fm p i, anbjecu the applte t t e c d penilry cid, ` _ e. `7 i not more Nell five hundred dollars ($500). vy .J ❑ I as owner of Ions propeny,m my employees with wages as their olecampensau n.. -. Required Inspections - - willdod osordeaod Neswcmre is nor mandMoroRcred (orW (sec ]D14 Buu and Preteritau Cade The Contractors License Law does not opPl>' to an cowner _ of it _ , property who builds or reproves Nenoa and who does such watt himself or through his own employees pmv dad That such impmeamenu are not intended m offerW for le h e thebuldi Ba pro met sold within a yearafcompleton the o b Id '1l havcth brile . riffouri,ml lhth did act build cur improve for pur. - a Via fsme) as w flheP pent uo exclusively contracting with licensed contracto t t me pro3ecl (5 7.44, Business and Professions Code) The Comment's Li- - • U ceme , s Use, a of a to an owner of property who builds m improver thereon, and , who c she u relic ra wi vutoi(s)liceneed puntummN Cmmuctoel i , L¢ense i ❑aim xempt r ��. � �. !/ F Owner _D t .y ' " WORKER'S PEN5ATION UeUI.AKA I IO (hereby flumn under penalty ofpeijury one ofthe following dationadma. I hose and will maintain a Certificate ofConsenttoscif —in far WorkersCompe sauon s Provided for by Same. 3700 of the Labor Cade for the petfomunce of the walk for which this permit is issued. - - , ❑ I h... nd will maintain Workers cempmeramn Insurance, as 4 gmred by Section' 370oflhe LaborCMe m work forwhich thisperntolssed' °i `',t s t MY Workers Compensation lasprentt carrier and Policy numbei en I, - iy, ' Carver policy NO - i, r• CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE' - (Thtaseclunrnad of becomput if NepermitisforonehuoMeddollwe (3100) • - v' or less) IcenifY Nat in lhepertartnence of Ne work forwh¢hN epemut is tseued.l hill ,, ;,.,., t - -b, n.1 employ any Person in any matter so as to become subject 1. the Workcra Campers " nauonla...f C.Iifoms_Dan Applicant NOTICE TO APPLICANT: IL atom making this unions of of Labor ion, you should - - , become mbjwl m the Worker's Compensation previsions of Ne labor Code, you must - r+fanh ith CO ply 'N such provisions or N' a t h 11 be deemed ked ,. d Q d CONSTRUCTION LENDING AGENCY { ' 0 work which R thi OU[Nererss4d M, I7,C .agency( the pert rmentt f a•, - - - r 'p• Leader's e work for whmh this permit is netsed ISe 3097 C . CJ Name �• •,� - q „ LeMereAddress t W /mow I arse( Nu I ha a e°d thie a b[j O d tan den to n0 f renal On'a t catnct 1 agree t omplY ith all ty tdI�ou rdmences and sul la Ming no ' '^ building slmction, and herebye "'qj'f� soflh' tyt nu uponthe 's rMV m seamed pro, for in c P N s ) (We) agree man in de fy an keep Fearless the City o `Cup rflmm against - 0 [) Itahihues)udgment, is and expenses which may to any wayaccneagatnst said City �+' [T] m co . q nee of Ne granlinB of Nis permio:- , ' 7 - �L•( 6e APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT T - U SOURCE REGULATIONS. .i. Signature f ApplicanUCnnmctm Date „ 4/� HAZARDOUS MATERIALS DISCLOSURE! 4/,o HAZARDOUS . V Will the.,icantofulutebuildrng eccupanlsmreorhaMlehaeardous matenal .Re -roofs -" I'' m depend by the Cupertino cipeI Cade. Chapter 9.12. and the H ilth and Safety s -. 1 ' Code tmtzss3z(rn .. TYpeofRoof a "- •. ,. '�' - �t ., Wdi th applicant r mull budding occupant weeequip Lord iceswhch A'1L roofs shall be'inspected prior towny roofing material being edit hawdous arcone�� efined by the Be, AraA Q Try Flanegem t installed. If -a roof is Installed without first obtaining an inspection 16 ° "° " - I agree to remove all new,materials for inspection.. Applicant ❑Y d Lill erstaiids and will comply with all nor[_point source regulations. ' (have c nal- mlmnnienos under ChaPOn 95 oflhe Cili t v _(, former Health S. 1 �2 5. 25533 and 25534.1 and find Nat if M1u Id' gd a ((t sets y nsibdiry to 'fy u afthe 4 e n mu rQ a faE ibdky f - / l'.•� SignatureofApplicant f, n .Date Owned or summiand agent y , Die All roof coverings to lie Class eB" or better OFFICE