00020111 CITY OF CUPERTINO .y 'ry^'„y tff, s,s 't?= )x.aY.w* m-" ;•b. : , w3z. PERMIT ND.
BUILDING DIVISION PERMITCONTRACTQR INFORMATION
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BUILDING ADDRESS:
to >• SANITARY NO. APPLICATIONSUBMfRALDATE
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CHITECf/ENGINEER PLurhA.h`?'_•a'P.d'Ai SDVI,DING'PE(2M1T'INI?G ,dy3
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O y z LICENSED CON'TRACTOR'S DECIARATON
y_p 1 hereby affirm Dat 1 un licensed trader Provi{ion{of Chapter 9(commencing Job Description
m 1-W Wim Smlion7000)ofDivism.JOf Ne Rusincasand PmfessimaCode,eon my liana is
m f; in full fora and affect-
al
vec A 1
i7 i raj Dc, Class Lis. Nle `�k/ �1 r
3 W y Datc GnnDEC V SI
u O a ARCHITECT'S DECLARATION
}� 1 understand my plans shall 4 uacd u public tmoNs
I
'u c O lacenaed Rofnuonal
t�+ 2� OWNER-BUILDER DECLARATION IC
Z a 1 hertby aRtm Chet I em exnnpt from Ne CoatnemY{License Lew
Airline
F O following reason.(Section 7031.5,Business end Pro2nim,Code:Any city or county
i 3 m which"rime a permit to transact,alter,intermix.demolish,w repair any saenue
pdono its issuance,also mquims the applicator for such pemdt to file s signedautimentFt. Floor Area Valuation
that he is licensed pursuant m the provisions of the Conmotore License Law(Chapter 9 n
(commencing with Section 7000)of Division 3 of the Business;cod Rrafeniom Cotle)or _� (� LJ
hu be is exempt haefrom and he basis for the dlcgM exemption.Any violation of A ,N3urnbe�� Occu surety Type
Section 7031.5 by any npplicam for a Farm,mbjau the applicant to a civil poral of (�'
Qt mon man rive hundred dollars($500).
1.as Owner of me lrmpeny,or my employee.with wages se rebate compemadon. Required Inspections
will do the work,and me saaum tiff-mire is not intended AereA forsal.(S...7044,Busineu
and Professions Code:The Conurcian's License Law doll not apply to an owner of
pmpeny who builds or improves thereon.W who does such cora&himself Or through
his we employees,provided the, Och hu no,menu are not intended or mental I.,
sale.If,however,the building or improvement h sold within one yet of completion,me
bin er will have he burden of proving hat he did not build Or improve for'Kin
t owner of the prepeny,am exducivelY eonpadin8 aim licensed comrecmn to
ns n the pmjea(See.704q,0minaa antl ProRulons Code:)The COntnmw9 Li-
tems Law does nu ply m an owner xf ptopeny who builds of improver dean,and
whocentnc pnjaraw.
wimecontnctor(s)Iicenud pursuenuothe Conttssmr.
Licenul r n
(]lam acme dr$q. .B@P' o; 's /
Data n
WORKER'S COMPENSATION DECLARATION
PIncrtby efOrm under penehy of pr,pury one of the follmvin8 dedantiom: /
have and will meinmin a C.niflcam Of ConswI t.sel(.insun for Workers Compen- O
m,as Provided fm by Section 37M of he Labor Code,for the performena of the /
k for which his permit is issued
❑1 have and will maintain Workei s Compensation Insurance,as required by Section
37(k of We Labor Cede,for me performance ofmc work for which this pecrit is issued.
My Wofke:s COmpemation lnsuamse lamer and Policy rumba an:
Cartier. Policy No.:
CERTIFICATE OF EXEMPr1ON FROM WORKERS'
COMPENSATION INSURANCE
or less.)
(This antero.need not he completed lithe pactis turner,hundred dollars($too)
'
1 ccnify that in he Perfommceof he work forwhich hiapetmin is issued,l{hall
not r,mploy my patron in my manner m t era hr,mra aubjat to he WOhr,n'Comam
cilium Iowa of California.Date
Applicant
NOTICE TO APPLICANT:If,afmr making this CenlGcetc Of Eumpdon,you should
became subject,.lie WOrtrfs Compensation provisions of he Labor code.you must
forthwith comply with such provisions-1 this permit shall be darned revoked.
z CONSTRUCTION LENDING AGENCY
Q (hereby affirm that hem is It conaomms,lending agency for perfrarmuse of
W the work for which this pearm is issued(Sec.3097,Civ,C.)
[..i Lendo's Name
Lander'a Address
W M. A 1 ccnify then 1 have read his app cetio an m that he above infotrmdon is
= z Co.,.I agree to comply with ell city tY y1�gpggs tied mm laws reluing,o
J building comnuedon,and hemby awhor a res Ileo see Oa city to areas upon he
ehove�memianed prop.ny far lnspectio purynse
(We)-gra m ave,indemnifyarM kap hassa euthe City of Cupeninoagaimt
v� C.) liebilitin,jutlgmrnu,cmmand eapcnus which may in any way ac......ina,dCity gg
J•' W in APPLICANT
Nthe grantingof his permit. �g
za SOURCE REGUL TIONS. OS AND N'Ii.I.CONVEY W'I'fH AL1.NON POINT
SOURCE NEGULATIUNS.
a•a
Signature ofApplua
H,clARutw
Date
AZARpOUS MATERIALS DISCLOSURE
Will the epplicamor fmun iptil owcupmtsmnor handle Henrdram mamdal Re-roofs
u tlefineJ by the CupeninO Municipal Code,Chapter 9.13,son the HW h ab Safety
Cods,Sectionu5u(e)? �(ppp//p�� Type of Roof
❑Yes )(o
Will the aPPllcmt offfuture building use equipment or devices which All roofs shall be inspected prior to any roofing material being,
emit hmaedous air cem,aminu[e as defined by the Bay Mee Air Quality Management installed. If a roof is installed without first obtaining an inspection
IV ❑Yes I agree to remove all new materials for inspection. Applicant
I have read the hWdet'smmti��rtquinumm none,Chapter.6.95 of Ne Cali- Understands and will comply with all non point source regulations.
forma Health @ y e,Sa ares,15505,25533 and 25534.1 urdemmnd Jut if he
of am ng dam u hevice¢nanj,h tismy pre 'bilitytonwifyheoccupa t
ser w.regairento, n-rebs merv , i „�n�_ epf.cr,n;rar6e�ofnraan,aa„
O .....Or an agent k/FAs —61/' .0Dam'['Mfa_ Signature of Applicant Date
Dam
All roof coverings to be Class`B"or better
OFRCE
1.