00020072WORKER'S COMPENSATION D: IARATION - 11d IA ,
ry 1herbyaffirmunderpenaltyofNrjuryo ofshefollowingd lnniom: n �® •. m
'Q l have end will nuinuin a Certificate of comenao.If -incur for Workers Carrier-
onion. a provided for by Section 3700 of the IaWr Code, fa the petfernnce of the f rep
❑ walk for which illnpernit is issued. es00 1,
1 have and will rem mm Workers Comps . von I sura ce, iyu'red by Section L
370lofthe fatter Code, Nedra performnce fthe ok for which this Perrot I. issued,
C Wark<n Compenanion Insurance comer dyN ynumbs arc ' /' r
Cartier MO FROM ' �/it�y /A,�
CERTD9C OMPE EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thisscetinn neetl not ecmnplered ifd. permit is forbne huridred droller (5100) r
or lcu.) t • r
I cenifylhn in IN peTOrmeme of she work for which this permit is invent, l shall • - -
not employ any tenon in any manner so ae to became whers m the Workers' Compere-
anion laws of CaBfomia. Data fa%
APWicant
NOTICE TO APPLICANT: If, after making d s Cenificaw of Exempdon, yon should
become subjcet m the Worker's Compenuuon previsions of the IsWr Canto, you ..at
forthwith comply with mcb Provla trim or this permit shell a damned rooked.
0 LENDING
'CONSTRUCTION AGENCY
IherebY eRrm thu Nert isaconwcUOOlendimg e8ency fords perfomunr of
Z tbgwark for which this pertid is issued (See. 3097, Civ. C.)
.F Lenders Nam, - ..
W A I certify Ned I have read Nie pp ni um Net to above iNorudim is
et correct 1 agree to comply wish ell ci . I car n near end auu laws rtleding m
U O ( bu ;Idingcmemocdom,andhembyam��yjc re re/:. nesetf biscitytemaotpontlr "
a xo a -men noosed Empeny, fm impec pts
W E:m (We) agree to nee, indemnify and keep harmless the City of Cupertino against
C.) Babilmax.Judgmenn, cnmarmd cape... which mey in any wayeremeagdnst said Cry, +
} W in comegoame of she granting of thn permit.
APPLICANT,UNDFRSTANDS AND W'111COMPI.Y WITH AI.I, NON -POINT
U Z SOURCE REGULATIONS. —
Smgmwn of ApplmenUComndor a Dam V(,(/i .,o 63
FUZARDOUS MATERIALS DISCLOSURC /' O rL
W ;Ilth e mplicamor future Wilding aecepanumrc or haMle haardaus mondial Re -rOOfs
as defined by the Cupertino Mon' el Cade, Chapter 9.12, and the Hearn and Safely '
Code, SectionW32m)+ Type of Roof r '
❑ Yu
Will the applicant Uram Wilding mentmnt u.ewaipmrmmd,o,i, w „;r„ All roofs shall be inspected prior to any roofing, material being
rWthaard ... it emanno urea define by she Bay Ara Air Quality Management installed. If a roof is installed without first obtaining inspection
an insecti'
DI „.
❑ Yea ”' Na d agree to remove all'new'materials for inspection :. Applicant
IW < the usmarmtivrdl rmrnuunnterChap695ofteCali- understands and will comply with all non point source regulations .
Name H I n S 10 Sectia 25505, 2533 d 255M. I a tend Net if she -
F ild;ngd ac ,, IYfuw:a �Ut Uul n_s Y sposuibiliryf�Ngpccu '
L7--c, arnn edeW.gepn V Signature ofApplicant Date
Dm
All roof coverings.to be Class "B" or better.
OFFICE
ct of corERTtNO
nO
BU ILDING DIVISION PERMIT
' '
CONTRACTOR INFORMATION:
PERMRNO,
'
4 O 2_(I 7,2—
BUILDINGADDRESS:
•
•
�a•11 ,ems+
SANITA RY NO.
APPLICAT3ONSUBMITTAL DATE
DWN}?R'SN
G
El
•PHD�
o
ARCHHECT/lINGIN^EE,H
HULUING PERMIT INFO
M-Z
CO
w �
u
-Sa,� t
,
v i
LICENSED CONTRACTOR'S DECLARATION -'
r
oy
z _
Grn (_u9
I herb earn that I son licensed under
r provmions arch,pmr 9 (ruminencing
with Secdon )000)ofDivision]ofthe BuainesaaM Profeaiom Code, aid my license is
.. Job Description '
- "
4 4` P
5
in full farce and affect.
License Clam Lic.N
O��,
/ e (/ ♦ �^l (/ i ��� t/ t
a g
ARCHf1II DECLARATION
' - -
vW r
1 understand my plans shell be mcE as public records
no
locoed Profeuroml
C 3 ¢
`
'OWNER.BUR.DER DECLARATION
w 1 herby affirm he, 1 an exempt fr the Lew
e Comnnes License fm the
F 00
Pollowin9 moon (S.I.O 7031.5, Bmimem, and Prafen ;wr Cade: Any city or county
i S
which rquira a permit m corm(Um, mar. improve, demolish, or repair any srucwe
Pose m is onenre. mo retain the applicant fmsuch permit m file a signed statement
S Ft. FloorArf:a
q. Valuation
that he is licensed purswnuo the Provisoes ofsbe Cone.mrs Lienme Lew fClupter 9
(commencing with Smdon 7000).f UOvia;on
r
� "
3 of the Businea and Profession Codc) or
Nat he is exempt therefrom are Nc Weis for the alleged exemption. Any violnion of
A PN. in a
CCnpUOejf
Section ]oJ LS by any applicant fm a pemdt sublecu Nc appllcanuo a civil penalty oQ
d mar than five hmmdred dollars
r
Ty
(5500).
❑ LasowmroRepropeny, ormy< mployeeawsh ..g...theiraalecompenadem,
will do Ne work, and thesbunurc iv imm�ddmoRcmd
' Required Inspections
not for Wc(Sa. )1104, Busincu
and Professiom Code: Te Cannactor's License taw does not apply to an owner of
Property, who builds or improves d e ean, and who does such wort himself or thtougb
'
.,
his own em Dynes, Provided that such improvemenn eR not intended or oRerM for
We. if however the building or improvement is sold within me yeti ofcomplOdon, de
•^
Wilder will have the burden of pmv;ng that he did rem build On iarrow, for pm-
'-
-
ofa..). I I r _
a owner of the PmPcMm , s eacluslvely contracting with licensed 'mana n [m to
the project . )010, Busimm, and Professions CodI The Contractor'. Li
'
tense law dots on y W an owner of pro, who builds or imyrava demon, and.
- r '
•
urease Clam, em Bk
wW,.ntnn ptejecu with bn67t.q , monspumnaniiii
r
Owner Data
WORKER'S COMPENSATION D: IARATION - 11d IA ,
ry 1herbyaffirmunderpenaltyofNrjuryo ofshefollowingd lnniom: n �® •. m
'Q l have end will nuinuin a Certificate of comenao.If -incur for Workers Carrier-
onion. a provided for by Section 3700 of the IaWr Code, fa the petfernnce of the f rep
❑ walk for which illnpernit is issued. es00 1,
1 have and will rem mm Workers Comps . von I sura ce, iyu'red by Section L
370lofthe fatter Code, Nedra performnce fthe ok for which this Perrot I. issued,
C Wark<n Compenanion Insurance comer dyN ynumbs arc ' /' r
Cartier MO FROM ' �/it�y /A,�
CERTD9C OMPE EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thisscetinn neetl not ecmnplered ifd. permit is forbne huridred droller (5100) r
or lcu.) t • r
I cenifylhn in IN peTOrmeme of she work for which this permit is invent, l shall • - -
not employ any tenon in any manner so ae to became whers m the Workers' Compere-
anion laws of CaBfomia. Data fa%
APWicant
NOTICE TO APPLICANT: If, after making d s Cenificaw of Exempdon, yon should
become subjcet m the Worker's Compenuuon previsions of the IsWr Canto, you ..at
forthwith comply with mcb Provla trim or this permit shell a damned rooked.
0 LENDING
'CONSTRUCTION AGENCY
IherebY eRrm thu Nert isaconwcUOOlendimg e8ency fords perfomunr of
Z tbgwark for which this pertid is issued (See. 3097, Civ. C.)
.F Lenders Nam, - ..
W A I certify Ned I have read Nie pp ni um Net to above iNorudim is
et correct 1 agree to comply wish ell ci . I car n near end auu laws rtleding m
U O ( bu ;Idingcmemocdom,andhembyam��yjc re re/:. nesetf biscitytemaotpontlr "
a xo a -men noosed Empeny, fm impec pts
W E:m (We) agree to nee, indemnify and keep harmless the City of Cupertino against
C.) Babilmax.Judgmenn, cnmarmd cape... which mey in any wayeremeagdnst said Cry, +
} W in comegoame of she granting of thn permit.
APPLICANT,UNDFRSTANDS AND W'111COMPI.Y WITH AI.I, NON -POINT
U Z SOURCE REGULATIONS. —
Smgmwn of ApplmenUComndor a Dam V(,(/i .,o 63
FUZARDOUS MATERIALS DISCLOSURC /' O rL
W ;Ilth e mplicamor future Wilding aecepanumrc or haMle haardaus mondial Re -rOOfs
as defined by the Cupertino Mon' el Cade, Chapter 9.12, and the Hearn and Safely '
Code, SectionW32m)+ Type of Roof r '
❑ Yu
Will the applicant Uram Wilding mentmnt u.ewaipmrmmd,o,i, w „;r„ All roofs shall be inspected prior to any roofing, material being
rWthaard ... it emanno urea define by she Bay Ara Air Quality Management installed. If a roof is installed without first obtaining inspection
an insecti'
DI „.
❑ Yea ”' Na d agree to remove all'new'materials for inspection :. Applicant
IW < the usmarmtivrdl rmrnuunnterChap695ofteCali- understands and will comply with all non point source regulations .
Name H I n S 10 Sectia 25505, 2533 d 255M. I a tend Net if she -
F ild;ngd ac ,, IYfuw:a �Ut Uul n_s Y sposuibiliryf�Ngpccu '
L7--c, arnn edeW.gepn V Signature ofApplicant Date
Dm
All roof coverings.to be Class "B" or better.
OFFICE