00020108 OF CUPERTINO `' ' �'O'
clBU PERMIT: CO NTRAC`•fORI ORMs1TION:
BUILDING DIVISION ''+,'i "
BUILDING ADDRESS
I # " SANITARYNO. APPLICATION SUBMITTAL DATE
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WNER'S NAML+ e ,
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N/C ., CONTROL#,%
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'ARCHITECT/F.NGINEF.R •d. _ ,
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FDi ,. . ' LICENSEDCONTRACTORSDECLARATION ,_ 1' 9^' ,. d' •
.z0,Oz= I hereby affirm that I ren licensed uw r pmvisimss of Chaplet 9(commencing Job Description .. '
H �w wuh Satloo and effect.
on3oftM Busm dual Pmt titan Cade eM Yl,ix se ,.
Lie
y in bill form end eRett �/�� 1 ` - l/�, �'^
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C 4 C faced eClau Com I Ye V Y F OV aQ�\
w 3 a y De¢ _ - Convector V
''ARCHITECTS DECLARATION -
•l 1 denuM my plans shall be used es brie records I`
+Licensed!Profnreonal - , J/ ' - .' f + #•_,
u� to OWNER BIRLDER DECLARATION ' a(`� ?•, c ' ..
(: r 1 hereby affinot that I`am.exempt B m the Contractors License Lisa for the
fall, aced (Seen..7031.5,B mess and Pmtaximm Code A y city or county
6 3F
width re9uves ape t t true Bier init demolish pair my em ma -w^
prim to its i.mana alsousirm eatheepph...t for such pemut m file I signM statement , Sq.Ft.F or Area Valuation
Nat he sl'ccmed pursuant to Ne provisions of the ContractorsLena Law(Chapter9� - _ r' QO6
., (commencing wim genian 9000)ofDrviaton3 fthe Busaanend Peofedimna Cad)m
that he is exempt therefrom and the basis f the alleged exemption.Any violation of APN umber ` Occupy Cy Type r-
Section)031 5 by any applicant for a perm t subjects she applicant to a civil pmelty of
ore Nan O's
hundred dollars($300) •'' ', - - -
p.t•mlaaownaofdon propsorit,myemploy a with wage.,as their'mtcompensamm. .. - Required Inspections ,
will dolled work,andfloomcma is not intended moRedd for sake(See90414,13mimu
and Pmfeesions Code:The Contdmors License Law das not apply to an owns oM1 ,
property who bo Ids or impro✓es themed,real who does curb wads himself df through - „y
s his ow.employees,inn idW that such tmpmvemems are am intended of oRerrd for - ' '- it, - i
We If, even the building or mpmveme0 Id within one y f mPlevon the. •f V _ ,
boiIdc illhave daburden ofpm 'ng that hed'd t baldermprove form., r
I s owner of the P operty ton exclusively c vacti g wi0licvl"c o-act to
on- i Ne projat(See 9044 Busmess and Professions Code)Th C vnctm W
cera La does not win owner of property who builds orunproven @neo d ♦ :' c -
whoconvatsfars hproJ cu Rheconue t K)ItcenaM ponumn Ne Conte m s' , ^
Lies/
a
❑lam em da See ' B&P for nOwn
-
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WORKERS COMPENSATION DECLARATION ,
i hereby iffi m under penalty of a J ry oa f the following
d«laeuom + -
[IIheeed will maintain aCertificam of Consent to selfimuto for Workers Comped _ r
sat on a.pro idea for by Section 3]00 of me Labor Code for the performance f h
wokr -
� f hchN-permtu @sued 1 '. - .
I have and will summit Workers Compensation Insurance,m required by section ,
3900 of Be Leben Code,for fic pedormaae of for work for which Otis permit is road. r i- •_
MYWorkers Compensation Insurmaceiriaand Policy number tic: ' ";t a„
CarricoPolicy No
cEffnFICATE OF EXEMPTION FROM WORKERS''. "
COMPENSATION INSURANCE
(nds saslm need am be cmnpleied if the permit is Intone huralred dollme(SIW)
or lesa)
Loy any perint in my annroas to become
for which UtapeWorlin'Coishell
not employ any Conon m any mentor so as to become mbl«t to the Worked'Comped_ - in
Amen Laws of Celi(omu Date
"Applicant t •. ° �' ,
NOTICE TO APPLICANT If.after modaing this Cemficad of Exemption You should -
r become subject o Ne Workers Compensation provisions of the Labor Cade,yin rest . 'v
forthwith comply with such provisionsorti's domitshall bedamed revoked''
'r CONSTRUCTION LENDING AGENCY
Q ' a' I hereby aRitm that Nem is a connmed lending agency for the performance f
ar+ the wick for which this perm tis'@ issued(S 309p Civ C) - l
tom'. �6 Lenders A - .
' a fir^ Lenders Address -
W 1 artifY that 1 lave
read e ties t SLf the that th bo information - I
Fa 0. corral I agree to comply '.all J o atilt..me aM t r laws Mai g
r�3 z building construction dheaby t u pr e t aofth' iIyt mWry o tm r ,
U Or abebemanmmd ProputY for ma chon Pu - `
W Fy .- (We)allies to save,indemnify and kap haunhem the City of Cupertino against ^s /
� U liabldi judgments,costs and expenses which may in any way@carne against said City ,I -
�., W Inco eq race of the grunting of Otis pent
[� 1 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON—POINT,- '' •_�(Jp ip� �I/(/J '
SOURCEREGUTATIONS.:
1
_ ,Signature of APPlicmtlCdniracbr - Dau '(�.Q /�N7\9 Aa—(/ee.,de
f RDOUS MATERIALS DISCLOSURE
Will themplicmtormhum Wildingnompantahreorhaddiehalsrdous mavriel Re-roofsd 4 - t _M1^•
n deflud by the CuNmno Mun c pid Code Chapter l)12 req Ow Health and Safay
Cm Sat 25533(r I 'I eRoof, •- '. -.
❑Y ph -
Will the PPl cant or core ildmga pito useequ pmeni or devices which All roofs shall be inspected;prior to anjjy��:1.roofing material being '
amt ha- does tium ummmtt as defmcdby the Bay Arca An Quality Management - installed. If a'roof is installed without LLrst obtaining an,inspectioii':
I agree to remove all new materials for inspection. Applicant "
understands:and will comply".with all'non poirit'source regulations.
I ha d the herard s ma¢nile req re t .Mda Iu'16=1
ta 6.95 of the Cllr
Tamm Safety Cade,Serums 23505 35533 1;255
I uialenimd Naz
,tiuil gd curientlyla Rnontlbmnis my rexprE, tonotifY Ne occupant
of @ray a ich a sueannifi ythe y.
Signature of Aopllcant ' ,�,+ t ^ Date :.
0 oriaw neem- D@d w'
" <r •All roof coveringsato be Class_"B"or better~
OFFICE