00020082CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDINGADDRESS'.
DWNFjIUA Af Z77M61eE A SS
PHO.\, ARCsIDs 3'o m3'o m
ARCfII'TECT /ENOINEFR'
LICENSED CONTRACTOR'S DECLARATION
O'Z ^ O. 1 hereby anion that I am licensed under provisions of Chapter p (comnxain j
F_tw with Salicn7")ofDivision 7 olden Busumosind Professions Cade, sd my license is
in full fame and.liml.
Ucense Chase Lic.a
3 u H Data Contractor
u� O g ARCHITECTS DECLARATION
y I uncienuM my plans "I be seed as public income
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a S Ucanaed Ro(easionai
nS ,� Oat I .. c UR.DER DECLARATION '
5 3z I heuby .(neon on I am eeempl from she L'amnclCra License Law far the
+a C D failmvin8 cease^, (Salton ece i.6. Business and ROessiona Curie: Any city a murty
ado
which requhes a permit re cansWpl, ainr, improve, demolish. file repair signed statement
Prior m its issuance. also requires
to the the isamo of dis Con Permit n ale aaigttd natement
(oc he is licensed pursuant 7 N) provisions of the , Ensure, s License Law , Ime)r r
(commancing thecuan wed of Divisionr of Needand Prt. Any n vi Code) or
Bathe is 31.5 attempt b any ad tau basis far the alleged esempsion. a civil vplaum of
Season e0. by any apd doll rs( • penrduubjan the eppliand in a civil pevlry of
El d mom than of hundred dome y employees L ot owner of the property, m my employees with wages in r Nei( sole compensation, s
will do Newark, ands: haCuisnotli U. Us, PL e. e4. Busiseu
and e-Y whans Cade: the Coat dam . and law doe non apply to lf owns 0
his We who build, ya improves thetmn. pr who does such works himself ei mamnfh
his own employees, provided that such improvements me ooh insedd a alfertd fm
s�^e oumldar w the builthe bur en of remenl h said within did n one build or improve den
r�build<r will have den burden of provin{ Net he did not build m improve for pur-
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owner of the pro say, ten eaclnsivdy contrening with licensed wntranon to
swtthe;rain,(S We, Bmhtussad Professions Code:) The Contractor's U.
cense Lew does not up an owner jproperty who build, oimpsuvu Nermn, and
CONTRACTOR INFORMATION:
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nor Arc
lumber
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N/C CONTROL#
/;'Job DAc�tlon� e�_5
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OFFICE
(]lemc ,BkP for Ni
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,owner one
,
WORKER'S COMPENSATION DEC'LARATIUN
la mby aRrm under p Oly of pc jury one of the following dalanlias:
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❑ Ihuveandwiilma waa Cenin=e rco otios if-insumfmwor e,Compco.
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sadim, as provided for by Section 7700 of Be Labor Cade, for the pe foreman of the
work for which this permit is ironed:
❑ 1 have soul
[A will mainnin Wn erfor Compemuian wails which ns rryuimd t i Section
of she Labor Cade, for the..eaaeof thework forwhich Nis pe(mil it issued.
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My Woekds Compansmion Insu(arKe cat(iaand Paltry number see:
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Ca
Carver. Policy
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CERTIFICATE EXEMPTION FROM WORKERS' _
COMPE
COMPENSATIONINSURANC6
(This section ceed not be completed JlMpcmut is (Drone hurdnedddlen (SIOD)
t
or loo.)
,
Net ofdee which,
Toy ricesueglsh
.n I. mynmee,
to do, W
not employ say become
Canon in any manner so ae It become aubjcm do den Wahen' Co.,.. m
of
of California. Dens
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A,liTaws
Applieanl
NOTICE TO APPLICANT: IL afmr melting this Certificate of Exemption, you should
.
become subject to the Werkere Compensation provisions of the Labor Code, you must
'
fdstbwiN comply with such provisions or this permit ohdl be demand invoked.
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CONSTRUCTION LENDING AGENCY
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I bertby afhmntaw Be. is a conmucuo lending agency, far the perfo. of
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the work for which this permit is issued (Sec. �9T. Co. CJ
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F. i4.,
'LCndcra Name
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a >
I rde(s Address
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1 cmify thin I have an th eppl chin a seta Bafthe above information is
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wtleel. l agttt to comply wish W co my a and ems law. relating 1.
-and
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builtlin {conaWCtitn. hcmby came, rc endives ofthis city to enter upon the
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abovo-memomd pmPmy for inapemion purCnsea,
(We) re indemnify keep harmless City Cupertino
agree nve, and the of we.,
r
Iuhilides,jdgmens, coon and expenses which may in my way acme against said City
in consequence of the grabbing of this permit.
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APPLICANT UNDERSTANDS AND WILL COMPLY WITH AI.LNON-POINT
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SOURCE RFGUTA'iIONS.
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SigvmreofAPpncam/Conmmac Den
HA RDOUS MATERIALS DISCLOSURE
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Willdeeepplic.a or fumm 'dingrccupemsmuor handle hatmolue mateml
as denned by the Cupertino Muni "' Code. CMpter 9. @, and Health Safety
Re-rOOtN
el the and
cede, .0 /
Type of Roof -
0yesus7aol
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f�N�'
Will the Wephcam.1f mrtbuiidingarn partmwe,npmentordevice,which
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All roofs shall be inspected prior to any roofing material being
haordou, air comical sunn a feed by the Bay Area Quality Management
installed. If a roof is installed without first obtaining an.inspection'
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I a ree to remove all new materials for inspection. Applicant
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The h
understandsl and will *comply with all non point source regulations.
farm. He &
M1uilNng n
ad yard anome, siyuirtmmde seder Chap 6,910 mu Cali-
f Y oRe. Soli 25 7, 25577 and 25571.1 ma ersnd deal i! the
c heveem i
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ofthe
sad as yusponsibiliry oilYlh
sore l be aCmi
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Signature of Applicant Date
Owne'rumuoriced agent Data
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All roof coverings to be Class, `B" or better
OFFICE