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00020073TY OF CUPERTINO BUILDING DIVISION t, PI BNGADDRESS: r/.29s73/x' R" NwME 5 r O Z LICENSED CONTRACTOR'S DECLARATION z O— I hmb Rrm that 1 m licensed udu Y+ Prone arse of Chapter 9 (common mg wuh Sa=ande)efpineion3ofrhe Busimnsmd Profeveiuna COde,Wmylicc is in me.na effect. license Clm Ioc 3 a y Date Co...., 4 . O w, 'ARCHITECTS DECLARATON C4 G I un4nuW my Plans shall be mad u public "ands „ lie a L,crosed Posted oral "' u OWNER- BUB,DER DECLARATION C 1 herchy JOB. that I en exempt from be Contractors License Lew Ire the i r O following rnaon. (Sntibn ]Ol I.S. Business W Professions Cab: Any city or County 3 which "quires a Permit m construct. alter, improve, demolish, m rtPat, any awmrme M' "'is issuance, also "quires the apPlicant for such permit RI file u aig,ud ammment . Out he is liunsed Pursuant to the provisions of the Connacude License Law (Chapter 9 ' '(commencing with Section ] 000) of Division 3 of the Busineu W Pnofeuome Code no tot he is exempt Nmfrom W the basis for On alleged exemption. Any violation of Secuon 7031.5 by any splices, fm a perms subjects the applicem to a civil penalty of ON more Nan five hundred dollars (5500). _ ❑ 1, as owner of to property, to my employees with wages as Nei, sore compcnaetion, will d6 *a work; and the swum a is ON intended or offered for eele (Sec. 7014, Business and Professions 'Com: TW Contractor's License Law does non apply to an owner of proper, wW builds re improves thereon. W who does such work himself or through -his own employees. Provided the such impmvemmis are not imendd m offered for We If, however the Wilding or Improvemem is mid within one yearafcompleuoq tie rider will have the sudden of proving that he did nor build on improve for p oar steel e of NE Propcny, m cxcluuvelY contrncrin8 with 1¢ensed contrmtm m co s the pmiem (Sec ] Business and Pcefeetes Cede) The Coomm airs Ls- c Moved «s nuts lry - cywwnNnuacoofpin ro pnywWWil& nmWov m mm .n'd who ac¢fa License Law m00hunme unuanuo] Contractors ❑lam cxem sad C ,B @P Ire that Owner CONTRACTOR INFORMATION: pERMT " °' C) o e7 20 ©�% -'__ �� SANITARY NO. APPLICATION SUBMITTAL DATE � - N/C - CONTROL# '❑ Is RUIDING PERMIT INFO Job 1Description /���f�✓�yy -x ' Sq. Ft. Floor Area, Valuation APN NumberO p;Incy. Type ' Q J - Required'lnspections'•.` (J n Ff8 1. U � Owmfar amlr. ag nt .'r7. Date Signature of Applicant Date All roof coverings to be Class "B" or better - OFFICE Date WORKER'S CO CNSATION DECLARATION V X2002 •' 1h andylRrmunderpenaltyof perjuryoreof . a lffallowing Workers Workman ❑ I have and wkulfil 37M CO C...., far .ion ce Or Me work as 1nov,dhi file by Section JJ00 of the labor Code, fm to peRomu«e o(Ne on. by Cad the work for which this permit issued . ❑ 1 have and will maintain Workers Compensation Ietu "name, a Inquired by Section •• 3700 ufWe Lobar Code, far the In-- the work for which this permed is rowed. .. . My Worker's Compensation Insurance tarsier and Policy number m:. - Cartier: Policy No.: ' , a .b CERTIFICATE OF EXEMPTION FROM WORURS' 1 - - COMPENSATION INSURANCE ' This ricureednm 4e,impletd iOhepetmit is torone W" dollm W 1 S ' mlcss.l - 1 I Cmify that in the lieffowance-of the work for which this pewit is issud,ishull not employ p y an y person in any canner m as to hccome subject to Me Warren Compcn- ,. - _ - • ' zero, laws of Cdifomia. Dtie APPlicmi - , NOTICE TO APPLICANT: If, after caking this Certificate of Exemption, you should ' f hemmc subject to the Wofkcfe Compensation provisions of the Lubw Code, you roue hunts Rh Comply with such provisions or this permit shall be deemed rtvokl Q Q • • CONSTRUCTION LENDING AGENCY I hereby affirm that Mew is a mnmucmo lending agency forth. perlommnce of - Me work for which Nis paned. is issued (S «. 1197, Civ. C.). - - '- E+ Kilo's Name - (� i Lenders Address , - ,. W0. 0 I Certify 'he I hive mad N 1 ad en au Nat the shove infofmgute is ;D 0 career. I agree to comply with ell buildingcomirucdon,andhembya 'p thud w my nut W rum Bwa meting m "n esenutivea of this city memo upon Ned ab nvc-mentiond property for inspection purposes. (We) F CJ ag"o to rave, indemnify W k "p M mlee the City of Cupertino against hatfiries.judgmenu, costa and exPems which may in any way secrue against mid City t ' • - - �e W 0- in consequence of the granting of Nis permit. a , ► APPLICANT UNDERSTANDS AND WILL, COMPLY WITH ALLNON- IC)INT - :.i SOURCE REGUTA]'IONS. /1 S,gnawnof Alocaroum ncmr HAZARDOUS MATERIALS DISCLOSURE - 0 Cr—; ✓ N�� Will Me applicant or future Wilding Occupant store or Odle hamrom mdcrid -roofs - - M de reel by Ne Cupcnino Munici Cde, Chapter 9.12, W the HeaIN and Safety Code, Section 1321e)a' .Re r - •fe a Type of Roof ;. ❑Yes Will the applicant or fmurt building «cupmr use equipment or devices which em, hasardoasairContaminants asdefined bytheBayAr eaAirQuality- m- genumn installed. All roofs shall be inspected prior to an 'roofing material being y If a roof is Installed first Disulctl ❑Yea � Iba.en.dN mate" I understands without obtaining an inspection agree to. remove all new materials for inspection. Applicant and will comply . d rCh. Torsi Zl & s y dons 21 0 ,35 3 W 255Ja. 1 undre5.95 afl Me r is mildingd«sna rrcn egmmnt. Naij(tgt rtspomibiliry mm /fv the «cu,um with'all non point,source regulations. 1. U � Owmfar amlr. ag nt .'r7. Date Signature of Applicant Date All roof coverings to be Class "B" or better - OFFICE