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00020081CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: .[) O Q 2 C7 O g l BUILD© ADDRESS: •1 . t SANITARY NO, 'APPLICATION SUBMIT Z OWN R'S AM ?: - T • - F NIC CONTROL p PHON' El ARCHITEC10761INEER BULDIKO PriRMIT'INFO �OO ! I' •. a (j F�F 7 c LICENSED CONTRACTOR'S DECLARATION ' 0 O = - 1 hereby .Rion that 1 em Iknaed tied. provisions of Chapter 9 ( commening p - - ;� _ Q Job Dcscri [ion qtr, i- an NSaticeandeecDivision3of dw Buainn[a�M Profevione Codc.WmYlicmwis 5a tiffs incen force and effect. /C� /• ,,/ _ d O,,,III ypLicense Clue' u.iN Date L'antr ECL ` / /'V G�� ,X �V' / a. '-• t u O g � ARCHITECTS DECLARATION , , - E �, 1 undrntand my plans shall be uud u public records i c g Licensed tamf iummil OWNER-BUILDER DECLARATION C X Q 1 hereby aff nn Nat 1 am exempt from Ne Cmaramr's License Law for the! - t' :F ,Q ❑ following reason. (Section '/031.3. Business and Professions Coat My city a munty' - F � which requires a permit to conW[i. alter, improve, demolish, of repair any x. 3 _ q. Ft. FloorArea^O� G I Valuation / O, prim to nee irunm. also rtquiacs dw Applicant for such pemit m file a signed nemmnt 7 Nat he is li[crued punnnt to Ne provisions of she Cotmatofs License Law (Cluµu 9 (commencing with Section 70)(B of Division 3 ofthe Business and Profession Call) in ' APN Number Occupancy Type thn he is exempt therefrom and Ne b.sis far lie alleged exemption. My violation of P Y YP Section 7831.5 by any applicant for a permit subjects the applicant to a civil pendty of 3 6 01 - ' pt more Nan five hundred dollar (S50o1. 1 Las owner of thepmpmt,, or my employees with wages an Neil sale conpeneadon. ' Required Inspections ., willdoshework.ataf Nr,tN um imot intended or offered far We(Sat.]044, Business and Profession Code: The Contractors Liaise law does tot apply to an owner of prapcny who builds or improves thereon, and who doa inch wort himself or through hlsbwn employees, Provided mat. such improvements am nth intended or offered for - f ale If oweve.the bud ding 0= ament is sold whin one yeas of completion, the s ' cw,ie n Oda wtil have the burden of proving that he did not Budd or improve for pur . x : J, L sal) k2 r of she Reopen am exclusively contracting wish licensed contusions to t the pro)ect (Sec 701I Business and Professions Code') The Contract Ws I.i c rte w daes ant ply m n owner o! propesry who butids onmpmvea thmrenn, aiM v. whocontrad. is pro1jectswim. ntrecto l)licameedpursuanjwCon-110.19 Licers. La ❑Iame alp cc. .B& f th' - Owner Dam s WORKER'S COAMNSATiON DFCLARATION " . I hereby affirm under Penalty of pe jury one of the following daWation: . ❑ I have and will maintain aCenificate of Corsumuo self -inau , for wokces Comµn- sation, as provided for by Station 3700 of the Labor Code, for the µRoranatim of the walk for which Nis permit is issued, .f ❑ 1 have sad will maintain Wark as Compensation Insurance, n acquired by Section' 0G n ! t 3708 of she Labor Code. for she performance of the work for which this Permit a issued, , My Woke's Compensation Insurnce cams and Policy number tie: center. Policy No '1. CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Phis seeslon neednm be completed iftleµmm is panic hundred doll.r(SIM) or 1en.) .� .. . , I anify that in the pelfommon do, work far whiclidd."I is issued, I shall - • anLamid, any µion in any manner n as to became odd.no the Worker' Co rper- ' satin lAwa of California. DVe Applicant NOTICE TO APPLICANT: IL after maturing this Cenificne of Exemption you should - him. aublect to the Wadeses Compensation provisions of the Lebo, Cade. You must Nostra, it comply with such provisions m this parmil hall be deemed revoked CONSTRUCTION LENDING AGENCY s ;� 0 Q I beteby atLtm that there is a construction lending agency fm the performance of Z.2 the weak for which Nis permit is issued (Sit 3097. Cit. C.) , (:. Lender'. Name qa > I<wee, Addles. ... [r] 1 certify that 1 have rea s ppl mi d star that the above infomution is d Q comeet.l agree to comply wi e c finance. nd .rare laws reladmg n 'V Q building conxwcuon. sad he ya h u Ares motive. of this city to enter upon tiro ' above mentioned µopetsy to inspection purposes, (We) agra to save, mdrandly and keep humlcu the City of Cupertino agein't - ... - C) C.i Iubilities, judSo,m. come and e.µnes which may in any wayaccmeagaimt rid City 2 y gI in cnsequcna of the sooting of this vernou. APPLICANT' UNDERSTANDS AND WILL COMPLY WITH ALL NON -MINT V SOURCE RFOULATIONS. Sigmaturof ApplicnVCmaractor Data ✓d w7f�V C� f ( .>Yl� •• HAZARDOUS MATERIALS DISCLOSURE Will she aPpllcnt orfuturt building m[upantamrem handle hassNOus menial Re-roofs in defined by the Cupertino Mun' ' I Cede, Chapter 9. 12, std the Health uW Safely Type of Roof Cade, section 25532(e)T yp P _ 0Yes Will the applicant or usurebuildingacupnt use equipment or devices which All roofs shall'be inspected prior, any roofing material being'_ rout humidn . deEnedbyNe Be, Anc.AEDuelileMnagement - installed. If a roof is Installed wihout £first obtaining an inspection I a ree to remove all new materials for inspection. Applicant ❑YNo Ihevc ma ereyuremrn under Chapter SafN C.li- understands and will comply-with all non. point source regulations. fmmr 11ea1N ns 25505 5533 end 8334.1 atMe lanA that if shebuilding= a rwm 's mY rtspunsibdity to iy accts of the require be et t o enifi Signature of Applicant Date Owner or euN ed e Date - ' : All roof coverings, to be Class" B" or better OFFICE