00020112 CITY OF CUPERTINO PERMIT No.
nmtuwc mvtswN PERMIT CONTRACTOR INFORMATION: tf��� -2
PERMIT
BUILDING cA`DDDRREESlS: N../` v `�°/
Ave
4 SANITARY NO.•• APPLICATION SUBMITTAL DATE
gWNEWS 4ME: , = I _
L `g NIC CONTROL#
- ARCHI'FEM7ENGINEER _ ❑ BULDINGPERMI'FINFO
-
- FI6z�
LICENSED CONTRACTOR'S DECLARATION •,
o x— 1 nerebr,.rfirm Met I am licensed under provisions of Chapter 9(commencing Job Description
p=t' wah ScAam7(00)ofDividOn3ofde,Business grad ProfeuimaCode,and my license is
w w f in fall force and effect - - .• '
Ow O License Class Li..N -
3LL Dme
ARCHITECTS DP.CLDECll ARATION New Four-eq�- 0�0,r-a9'e
-
2 <I lunxnued myplans zlWl be used upublic rtcads
oLlanacd prat..tonal - . , t .•
OWNER.BUDDER DECLARATION -
t: 1 hereby aRrm Nv 1 am exempt from Nc ContruIo's L License se Law fm the Is
Ofollowi g resson.(Section 70315,Business and Pmfesnoai Code Any city or county
3 m wluwh req sec a,also
m mruwcl alter,Improve,xmohN m pair any sommot - S Ft. loor A ea
PB b1 rmgrsuantq theapodicam Me Con permit to Tl s greed Ch.,tw9 (i• �� ",Q Valuation
Nut he n licensed pursuant 10 Ne ofDivision
provisions 3 NC Contractor's License rgum Chaprtt 9 l7 Q(J
t a,he I,green to mear ,Socoar,and rDivini for of Nee'airuu grad on.Promy
Cde)m •�
Wt he is 31.5 b anrtrrom and tad pais for Ne Subjects
Man ammption.Any vlmd.n or ,, - APN Number Occupancy Type
Section Man by an applicant go,a 't Sub'
Y PP IX19 Nee II
Penin 1 cant to ecivil tee Of
nm more Nen By
PP Pc ry
Eve hundred ..
❑I,n6w ork,andpropeter,mmYmintendedwwwagef ned for We
Required ins et' ns
walxmc work,and Norse Conoseeg Lot. Liesdolt Wefplyt.ga,Buainn-,
sn0 '
Profaasiom '
Cla-1 lone Cor Mager s License law deo not apply s if sn ser of
his amerty who build,or impmvn IWahn,and who dose such work himself ormad f h - -
big own employees,povidd tMl such one" mmu we nm inundd m oRerd fm -sale.If,bower ,will c Wilding m improvement is sold witin Otte rev of wmplvion.the
rWildtt will lure tad burden of proving that he did not Wild m improve for Pur.
of lite.). .
.. 1,u owaer of Ne proper,un exclusively contracting with Beans#cono-anma to - _
0o mere ro em /Oti
- p I (MWO
.sed w.s.( up Prof gram
e "ns CdeO The Conunmoh U-, r
vshoorroemsnowarofrectoo wlw Wile or im,go Me Nen.n,end
wW coecu wiNacmtrectar(r)liunsed pusuaoume C.ntrvtot-
Liana '
D lam - ,BRP or mix noon
Owner Did.nderp OM PENSATION DECLARATION '
1 hereby eRrm under penally of perlury mm of the following declaration,: '-
❑Iluve aro will Ing
tee tion;37M ofCon,enuo selLimum for WorkeYe Compete- - - t .•
smion,an provide)fm by Section J]00 of me Labor Code,for the perfomunce Of the
work for which this permit is issued.
E 1 have and will malnuin Wwkel,Compensation Wmance.as required by Section
37M Of the LaWr Code,for the performance of Ne work for which this potent is issued.
My Worker's Compensation Insurance cvdm and Polk,number am
am'.
Carl Policy No.:
CERTIFICATE OF BXEMP ION FROM WORKERS'
COMPENSATION INSURANCE -
(Thiisecone nod rot be completed ifif.permit is for one hundred dollen($100) s "
I orally this in Ne panformvue of Ne work for which this permit is iuued,I MaH
not employ any person in any manner so as to become subject to the Wo ows-Coopers- -
ganno Law-of California.Data .
Appli.,
NOTICE TD APPLICANT:If,after snaking this GwdBnm of Exemption,You should - -
hecome subject m the Workel6 Compensation movisiom of Ne Labor Cade,you mon - -
fottwlth comply wit such provision,or Nis permit-hall W deemed
zCONSTRUCTION LENDING AGENCY,
0 Ihenbyfsnnmai NeQj7--
m'
mlarMingagrnryfor Neprounamoeof
Me work for whiNis permi309],Civ.C.)Landers Name
lanxls Adeno0 1 mrury Bio 1 have •damsButteaboveinforam imi-corretIagrreso amply wtlinty mdinencea erW num laws rtleling mbuilding conswNon.anJ ha pnzenmivesoftisrnymeme,.per,a, -
V above-memioned properly ror n,prcdnn purpmes.
0 LL [r (We)gme m save,indemnify endkeep ayinmsthe Cityor Cupertinoagain
W liabililin'te..fava, mingwita and xpensezwhirh may in any wry aameagemn aid City '
} 91�k7 inPPLICA TUN ERSI NDS this permit. • 388'va J `
z APPLICANT ULATIOfgNDSAND WILL COMPLY WITH ALT.NON-POINT LTfi
V z SOURCE REGULATIONS.
r. SignaturtofAppbant/Contncmr Data Joe
HAZARDOUS MATERIALS DISCLOSURE
Will Me applicant or future Wilding mcupam sinm or handle Wramous material• Re-roofs
u defied by the Catarina.Municipal Cde,Chapter 9.12,sand err Healer and Safety - '
Cde,Section 2$$R(e)? ' Type of Roof -
❑Yon ' - -
Willtheapplicantmr . building Occupantuaequipme.,ordevices which .All roofs shall be inspected prior to an rcofin material bein
coil hodrum,air commum mn ex defined by the Be,Arra Av uail Mama rmem y i ,
Do.,,i Quail, a. 'installed. If a roof is installed without first obtaining an inspecttori
E]Fax I agree to remove all new materials for inspection.;Applicant
IWve gerarumsronye,�.`;amanmunder dhapterb9;oil MeCall- ,understands and will comply with all non point source regulations.
Ymrtia H a cry cox. 1ssos.ss$33 grad zss3a.I o xnuad Nat Ir the
.
boildin dm n v telly Neve 1 t 1.Nal it is mY rtipnnsibililq not Y l e occu ant • -
of to air n i mus be )1 u'pso.ice of is C Y e cap - -
Gwn Nonad.geniSignature of Applicant Date
.. au
All roof coverings to be Class"B"or better
OFFICE' ,
t •