00020105` CITY OF BUILDING
UDPERTONNO CONTRACTOR INFORMATION: reRMI 1 _
PERMIT O O 2 O
211'
INGRESS:
SANITARYNO. AI'PLICAT[ONSUBMITTAL ATE
NAME: 8 _ —cig
,r - NIC - CONTROLp
ARCHITEUVENGINEER` + - HULDIND PERMIT INTO
Is c1q
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t_M i LICENSED CONTRACTOR'S DECLARATION
O 0 v C I heaby arcum Nat I w licensed under pmviaiom of Clupta 9(wmn.neing Job Description '
with Sationl )of Divisionlofrhe Busincsaand fessions Coq .ylicenuia -- -
tin full farce and eRc".
o LIan.Glan x New Fo.0 r-
w 3 H Date - Contrecmr '
C O ARCHI'TECT'S DECLARATION
's ash i= 1 undemraM my plans shall ne used as public records
��,, L
y Licareved Professional
OW NERC exempt
x a from
DECLARATION
C?< I hereby.(Sero .n enInas 1 emapt from Ne Contractors License Law for the, y
p following reason.eamhon'l031.A Fundamental Pmfessiom h,or Any city of ..
which agnssunealso tocomebef.i.tmet,alter.improve,h porm,n, firepairwy atmrean Sq.Ft-oor ea Valuation .
pri r hurt he
thof fm taco pemNmicenseaw(Chater9 'O O
that he ie licensed Forecast to the Provisionsof the Conrrwmrs License Law(Chapter '
(commencing with Section 7000)of Division 3 of she Business and Psofeasiom CMS)m ,
War he is exempt Inmefmm and Ne basis Cor the alleged exemption:Any victim.of 3 rn � - Occupapc Type
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penally of (� I 7
pm more Nen f ve nurdrcd dollen(5300). \J
h,as owner nrthe pmpenr.or mr employs.with wageam rneir.nle enmpen.tinn, , - Required Inspections
will do be woek,.nd Neauucwre is em intrnded oroeered for into(So.1044.Bmine.
end Pocemiona Cade:The Coku ecmri License Lew does not apply to an owner of.
his
ny woo oyildx or Imymva such
h atal:ho does such work intended
or m Nrougr
his own employers,provided Nm mcM1 improvcmmu art not imc,Wed or orccrtd fm '
Wa.lf,hower will h ver the
orempmpouts 6mld dui
rtoneild or iromple for Ne
o rWilda will lure Ne Wstlen of proving Nam ve did nm build or improve for pun
-
I,assweetofct piopeny,esn cxdual am conuwuns won:)Tan Contractors
contractus.i-
ct
thedoes
nem(S o na Business rod Professions Code:)The Conum rm Li-
cenx Law does me ap ro en owner of pmpeny who builds or improves contra,end
wicanw rant jam with eco tor(s)licensed pummrtmrhe G9nlnaorr
' License La s CI I. cmpm u
Owner Date 'Ike
WORKER'S COMPENSATION DECLARATION OOL'
I hereby affirm under penalty of perjury one of Ne following declarations .• - !"•p U
Ihave andwillmainmineCenifcau of Comenva xlRinsurt fur Workers Compcn- ^''' 1'TG
cation,es provided for by Secure 3100 of rhe Labor Code,for the peBomuna of the , p�
work for whdh this pends is issued, �U1LD1��
❑1 have and will oda,fon Worthieh,pedo Compensation Imuratwhi as tequved by Section - m
MyOof Nes Co CodgionNsurancnnence ,the work fir which this pertnis is iswed. u
-
MyWorkersCompcnutionInsurancecerriaendyNo.:numver art:
Cardec Policy FROM
CERTIFICATEOMPE SATIONIINN FROM WORKERS'
r COMPENSATION INSURANCE ,y y it
(ibisaatinn need nmhcompleted if the pcnsnr is forme hundred dollars(5100) -
I certify,that in the perf tom..1 be work for which rhii permit is iuoM,l atiall
not employ my person In my Winner m as to become subject to de Worker%Cempen. -
.tire Law,cf Celifomie.Data
APPlieanl r e
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you abauld _
.hecorne aubjaeto the WOM's Compensation provisions of the Lnho r CMB.you..in [, t
fonhwid,comply withsuch provisions on this permit shell 1,clamed revoked. J
CONSTRUCTION LENDING AGENCY
O Q (hereby affirm that Vert is connruct,on lending agency for the performance of
the work for which this parmil.issued(S 3097 Cis.C)
(.., (.enders Name ..
Qe, Irr�� lender,Address
W Q I candy Nat 1 have rt hi appl u d tit Nanhe shove laws
minting
i
f� z corrtm I agree Io comply thereby
d co teNimncea and sum laws r upin t to
`7 building construction,andhor impauo ampreunutives of this city mcnur upon the
C.7 O ebovernemioned property for inapecuon Wryo.s.
fgv E: (We),gra m ave,iMemnifY end kap harmless um City of Cupertino a8ainst
O C.7
in
nconsequuce of the cmoaM ex penxawit. rmyin mywry accmeagalnn.id City a S (,IT—
(a] in<onuquemme of the granunB of Nis permit.
p'+ APPLICANT UNDERSTANDS AND Wirt.COMPLY WITH AIA.NON:PDIN'1'
SOURCE REGUTA'rIONS.
Sill.uf ApplicanVCm.or Dam _jDe-
J ♦ �•f• t
HAZARDOUS MATERIALS DISCLOSURE - /`�NvC`•
Will the applicant or future Wilding occupant store or handle heuardous maudel Re-roofs
as defined by five Cupertino Muni I Coda,Chapter 9.12,arta Ins Hea1N and Safety
Code,Session 25s32(o+ Type of Roof -
CY. „ . u ,
Will the applicant or future Wilding occupant use equipment or devices which All roofs shall•be inspected 40prior to any roofing material being - :
iNtl,al WsalrcnntamnlnMa definedbytheBrca
eyAAirQualityManagement installed. If'a roof is installed without first obtaining an inspection. '
is..E - I agree to remove all new materials for inspection. Applicant
❑Yet - Ne Gd
In ave rend ws mamriaH masneer
tiherue�ta Gha;arb.95 of Glia 'un erstands'and will comply with all non point source regulations.
Como Health&. IeIY Section 5U5 55J3 end 23514 onde Nar if rhe - -
,coldingdaesn currt I amnan rm it smY usponoM1ditym d
of dm mryuuam nu wni rant I is Nfic '
nature of Applicant Date
Owneror eulluniedv8em Dam ,
All roof coverings to be Class"B"or better
OFFICE'