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00020075CITY, OF CUPERTINO .. : - PERMITNO, ; Bun.mNCDrnstoN .'PERMIT : CONTRACTOR INFORMATION: (� ©� 2 BUILDING ADDRESS ' - - "1S r �/ �a -/'� t •,� I J ', SANITARY NQ APPLICATION SUBMITTAL DATE 064a A, OWN R'S NAM rC. - •f.L,f C //` /-y - i CONTRO p L . - ��GS N/C L ARCHITLCT /ENGINEER © r B ILDIp" P {�{I'P 1 I. �U U t l - t- J Z LIn that C'ONTRACnORS DECLARATION '' o °z 4'o I nerebr.frrtn m.t L we heemed under provisions of Chapter 9 (wmme 'ng •t - Joli''Desulption with s «rroa 7doffeeDivuion3.f me BUSim naiWR.fnmon code. end mY lice . - �! y S a m full force and eRttt. 'Omen Cleu Co... " f O "� , ARCHITECTS DECLARATION' / • •�A ,`� 1 w. a 1 understated my Plans abet] be used a public records '� �% ! /e] • . a e g o Groaned Profexsiond -. aGGG(JJJI / T �' /.` `f 6 r u7 'OWNER- BUBAER DECLARATION 1, C r 1 hereby a0iim that I am exempt from the Contractors License La for the. ,. S q folleming roaxon. (Section 7031 ,5. Busiruss and ProRmons Cade Any city or county " ' - c. 3 m which requnes P< t to htr [ all improve, demali.h or repair any arm, Sq. Ft Floor Area - 'Valuation prison, [ tt. also aq tome eppl'cant FOr such Pemut m fl a gnedrtatemen( math I. licenred pursum1 the prof its of the Convector aLcrn Law(Chapter9 ' ', ,. - (commencmgwith Section 70007ofDivis 3 of fn Business—.., r mcaa) r .. - Number ...Oce an T e Net he is exempt therefrom end me bail f Ne alleged axe -pt . Any violation of )' y , _ I -t on 7031.5 by any applicant for a Perot subjects [he, applicant to a civil penalty of 3,�' s I math mm five hundred dollar (5500) - - - ' '❑ L as nwnu fthe property. or , employees with wages an then le compensation, ri. Required Ill spections" > , will do the work. W me auuctme is not intended m offered fora], (Sec ]014, Business - \9 } ,and Profeuiotu Code: The Contractor's Lianse law doea nth apply man owner of property who builds m improves thereon. mid who dos such wmIc himxIf m though' -' - • i,. his own employxs, pm 'dad Hot such improvements are not meanded or offered for " 59 If h war, me budding or impovemrnus sold within one yemofcompiem me. t ow Ider will haw me burden of proving ma[ he did rat build or improve for pu- 11 . I • ' r r f pose" ale.). tier of the pro ny ern caclusively conne«ing with h eased contact m con a proj «t (S Tp44, Business and Professions Code) The C nett Li- so ' la d to 1 tomown<r ofm pert, who build.., improve. thereon and' c tact ar Lx wimac.n tok(al ii<enxd J pursuant tot Contru[ors f, Icon I mptu = f_'s ai JCS/ t "Owner x e WORKERS COMPENSATION DECLARATION the bye under penalty of" Fro, own fora "',own, declaratiom - •. ' ❑ Ihaw and will m main a Cemgcam of CO -tai If -imuref Workerscompen sau p idol for by Section 3700.fthe Labor Code for the pest rmitace miles f work for ml, pre t issued ' •' ❑ I ha nil ill mat ur n W ners Compensation Insuanc retuned by Sato 37Wrfine Labor Coils, for the pieformance ofine work for which this permit isuued, My Worker's Compensation Insurance came d Policy number art: Y.' Comer Policy N . i - CERTIFICATE OF EXEMPTION FROM WORKERS' „ y .A _ •.' COMPENSATION INSURANCE .. CE t a (Thrs xminn need notbecompleted i(me pemui in PoronehvrWreddalan (5100) i.,. • _,i, ,' r r A } .x v "or less.) ' xd i 3 (certify maim the performance ofine wmkf.r wh¢hmii pemut is not em to en man manner. m io become eub'ai to the Wurkere Com P Y Y person Y. 1 Pen - satins Laws o(Cehfomia.Dea " n ^ APPlicent NOTICE TO APPLICANT. If, after making this Cti ifcato of Exemption, you should ✓' T become sublat tome WoM'e Compensation p stony of the Labor Cade, you Forthwith comply with such provisions or this pomu inwH Screamed invoked, ,•� L,CONS'rnisa, ON LENDING AGENCY' aei - ,O Q. kf by lh dus em Riaaco a[ry uon lending agrncy fonhe perfomun f <. , the work for which ors permit is'sxue (Sa 3097. Cis, CJ F., . Lemke, Name , lenders Address» - y I certify met I have a li eM state mat the dhow odmoution's - i - a correct. 1 agree to comply w h sit an w ty ordinances aiW stet= laws.]at ng m U O buildingcmemostion end ebyaul nu rcpresenativea oflhis city to enar upon me • ',i '- .1mvementionedpi,a f mapecuanpurpes. * - - W F , (We) agree ro aw. indemnify and ke p harm) s the City of Cupert via against' V Imbildia,jodgments; cots and expense which may n any way acmeagainsi and Cny' -- 1�y "W In consequence of the grunting of this permit - APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT, SOURCE REGULATIONS" .. Sign t fApph,,ant/C t t - - , Data ,Ja 'e • - F� /v / ti e t ., HAZARDOUS MATERIALS DISCLOSURE ,' V CG t • �' - ( Will theapplicant orfutute budding Ncupem store or hind]. humedous material Re-rOofs 1 as der ed by the Cupemno M n pal Code Chapter 9 12 and me Health aM Safety code Se non 25532(.) , , Type of Roof ❑ Y Will the pplicmtidingmcupuituseequipimniordcvmeswM1Sh All roofs shall be inspected prior to any roofing material being ' emit hasardmi an.nnWm r defined byth Bay AreaA Quality Management installed I£a roof is installed without first obtaining an inspection ° " ° "] = I agree to remove all new.materials for inspection. Applicant rpYes . d Ihavecud h usmatamu, enbuiiderChapt«695 to Gabe- un erstand's,and�will comply with all- nonpoint source regulations. - forme Healtti & fe e, Seniom 3 and 25334.1 unders a that if d¢ .M1uildin g does cu a amnem mapons bit tymnml me «u tfthenooue is m t eyte[ Nfceto eau cY. a I ature ofApplicant Date Owne .real etl get Date _ , -• _ All roof coverings to be Class`B" or better a OFFICE