00020106 CITY OF CUPERTINO - •- . - PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: O.O K7 Z CJ
BUILDINGADDRESS. •1
I - 1 • SANUARYNO. APPLICATION SUBMITTAL DATE
aickn6v Aye
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NIC CONTROLg
9 F ARCHITECT/ENGINELR - BULDINO PERMIT INFO
a o LICENSED CONTAACror S DECLARATION
O Z_ I hereby alRrm that l.m licensed oneu p,ovivoiu or Chapter 9(mmmere g Job Description -
p:l_u9 withSa1m.7000)ofDivision Sof the Business asd Potain .Code: my license is - - -
4force and cRect. � IAC\1j.�. /}��I '� l/'3 n /`''�1k '
5w d p2, .D to class Conuacmr _ 1 �VvV -,W:� r J 4 rqC��
C�O� ARCHITECTS DECLARATION,
E v't 2 I undersand my
Plans.hail be osnd es'public mcads
00
oaaff utemM PmfessimW ,
OWNER-BUILDER DECLARATION
C Z¢ 1 hereby M.that 1 am exempt from Ne Contractoes Llcerse Law for the
O foll.wine rcvaon.'(Siston 0031 S,Bmineac end Profeuiona Csde:Any cit,m cmnuy •.s 7'
watch requires. a m,m construct,alter,improve:demolish,or tapair any ononcorc Sq. Pt.Floor,'Are Valuation
mart.in issuance,also set the applicant for such persist m ile uigtrdilaamem )
Nat he is liumed pznuantmNe Previsi.m ofde C.nvactola Ucense Low lCMpa9 - 'T C2 j>3�
(cors AcingwithSadon7").fpirHl.n3ofthcBasineasmdNofessiomeode)o` APN'Number Occu arts Type
that he is exempt therefrom and the basis for the alleged exemption,Any violation of p y yp
Section 7031.3 by any applicant for a worriuubjacts the applicant to a civil penalty of ' �t 't
not mom than five hundred dollars($5W). V
❑Laaowatt.,thepropcny.mmyemployeeswthw.ge.uUteir..le.ompewd.n, Required,Inspections
will do the wurk,aM thenrvcmm isnot intended orofierod forule(Sec.0060.Business ,
'and Pmfessiom Code:The Contractor's License Law does net apply to am swner of
property who builda or improves thereon,sod who does such work himself or through -
.his mwdemployeea,pownhid this such improvements as am intended or.Berea for t .1
'sal zfF however,the buildingorlmproyemem I.sold within ane yem.f.mopleakin,the e -
owesro•W Idtt will sane the When of proving that he did not build or improve fm pis.
Ne.).
ntt of ate property,am exclusive[,conoecung wed licensed contnnon ro
'constm t fee p.jed(Sec.7(66,Business end Professions Code)The Con.acmi s Li. -
•cense Lew das out.,IYA an owner of p.,ny who builds or improves thereon,and '
whoconvaasfor p ctay'ithac o Olicrosedpiesuanuo ContnaciMs`
License Law,
Law. I
❑lam exam on ,BAP or tats • ALE
®Owner Data -
WORKF.R'S COMP Sju ON DECLARATION s
hominy eWORIunder penOtyofperJury one ofCLARATIO dalanti.m: ��� � �• 2��Z
I hevemd will mainuin a Cenificei Comsat m self-inSum for Worme.Compen- - '
sation.as provided for by Section 3700 of nu labor Code.for the performance of be
work for which this permit is issued. %'.,
1 have and will maintain Worket's Compensation Insurance.as rryuved by Section �U I LDI I V L7 1
.3700ofthe labor Code,for the performance o dre work for which this permit is issued. : ,
My Worker's Compensation Insurance coma and Policy number art:
Cartier: policy No.: • '
.CERTIFICQE OF EXEMPTION FROM WORKERS';
COMPENSATION INSURANCE '
(This settiwt need net be complerM!film prmtit is faro.hundred dollars(1100)
or los.) - '
I moo,flet int he rerformenceoflte weak for which in.pdrwt is issued;Ishell
.1 employ.ny person in any mins m as m become a.bjmt to the Worker.'Compcn-
r cation law,of Califomia:Data
Applicant -
NOTICE TO APPUCANT:IL after making this Certificate of Eeemplon.you saould
bac vm subject to the Worker's Compensation pievisi.ns of the labor,Code,you must
forthwith comply with such provisions on this pdmilshall be deemed revoke.,
Z - CONSTRUCTIO LENDING AGENCY I
0 Thereby dfn nNU therci ew ocdon lending agency future perfomu.eof '"' '•f
.ZZ the work for which this permit is i ue (Se 3097.Civ.CJ - I
E. Landn"Name
a [r` Isndets Address
W ^� I certify Jut 1 have rc N aP li do and s.¢jhm the above information i.
.a7 comet I egme m cmnply whh II cityd county on manses an t.ue laws reled.,t.
building oncenmetion,end hereby amhom.repexnwimeof this city on enterupon the
C.1 above-mentioned property for inspection purpose, - -
W [.. (We)agree an.ave.indemnify and time hamdcss the City of Cupertino against '
C.) liabilities,judgments,cosuand expenses which may inany war accrue against said Cityiti ccuot,theic of the
' CLI APPLICANTUNDERSTANIS AND WILL COMPLY WITH ALL NON-1411 NT• • . - V .+," � ,�
tool z SOURCE RCGULADONS. '•i _'
_ Signature ofApplicant/Comnctor Dae . c,/(J�i
HAZARDOUS MATER[AIS DISCLOSURE yGt
Win the applicant or future W'1d' g mccupaml store or handle hazardous material Re-roofs
as defined by the Cupemno M pal Cede.Chapter 9.12,and the Health and Safety -
eodaSen..n25s3H. ' ` Type of Roof
❑Yea qT�y
Will the applicant., sane budding.cupmn use equipmem or devices which All roofs shall be+inspected prior to an -roofing. material being -
01 ionob".wnfims air continuum...as defined by the Bay Area Air Quality Management installed. If a roof*is installed without first obtaining an inspection 1'
I a ree to remove all new materials for inspection. Applicant
❑4.nmw
g
I h .us matmida understands and will cors I :with all non point source regulations.
rtyuirt rnu weerCWpter fi.95 of the Cain P,Y P •C
,.chin Hi. Savors 2550 255 3 and 25536.I uderst d that If Oce'
'building d. v .1own(th isrt responsibility m naJ the cu
of 1M reytot t pri t is ifice n Eeu�mry^ - •-
attire of Applicant - Date
Ow.rms. adze gem - pate
'''All roof coverings to be Class"B••or better '
OFFICE`" `' „