00020113 CITY OF CUPERTINO "
BUILDING DWISIOrt PERMIT PEwMINo.
CONTRACTOR INFORMATION: " 000:1d ' .r
BUILDINGADDRISS:
) SANI'T'ARY NO. APPLICATION SUkBMfrf LDATE
O\VNER'SAMG: a - r
1` - NIC CONTROL#
.i ARCHITECI'/ENOINEER a "
BOLDING PERMIT INFO
rcU C
ZZe
Z
F. LICENSED CONIRACIOR'S DECLARATION
16ertbY eRrm that 1 em licensed under Provisions of
Chapter 9(coymmencing
wiNSation7000)ofDivision3nd s - Job DCSCfIPIl01 +
in full tome aMeR<c A -
u"7 3 LL u
Data
Class _ can—Don—
N� A J \ bu CO.r Qq rq ate -
Deu Cornu ECL �(V `JI
(:L`O S As"I W TS DECLARATION -
j, 1 andersmntl MY Plane shall be tied a Public rcwNa - ` // � +
°•k o Wcmad Nokamrul /`-7. 1
OWNER-BUH,DER DECLARATION "• I ,
C Z I bertbY aKn toes 1 un eiempl from the Contracture Licanulaw for Bic + -
I I=❑ following rcaaon.(Section 7031.5.Business and Prefesilona Code:Any c,ity or county ,
which mqunes a permit as compact,slur,improv",demolish,or r<pmr any a owfir. Sq. F[. Floor Area
prior to maiauana.slso requiree the When.,forsah protonsm File. igoodim<ment Valuation '
tut u is Itermed Parsaant m the Provision$Ofd¢Conductors Licenu Law(Chapter 9 �'
(commencing with Section]000)at Division 3 of the Basin..hnd@of.sians Code)or '" r"
But he is Cumin dereefmm and the basis for she alleged exemption.Any violation of _ AP bar .,Oecu enc •f��
I0
ectiorc on 7031.5 by any applicant for a permit subjats the applicant t0 a civil penalty of p y`7 pe
0ImNen five hundred dollars,(3500). • I fUt�f
L asawmaofthe property,amyamw ploywith wages as meirselecampeaaati0n. Required Inspections
wNe wo
ill do rk.and Ne ewcwrt im
is ma eMed camfered instal.(Sea.7014,Business
and Pmfesaiam Code:The Conesact--Licenu law does nor apply m an owner o/
•e property who builds or improves turcon,W who Eaer such work himself or drought r
his own employe.,pmvidnd than such improvements son not intended or oRernd fa ,
sale.If,however,thC building or improvam<nl is sold within one yearafcomple,on the
ower-builds will ham the Wrdan of proving Ion Writ nen build or improve for par- '
pose aiftste.).
• pay.• of N<Property,am inclusively conaasing with IicenuL coma' O.O,m - )
�o0swcl Ne pmjat(get.70,11,Bu5incu 4 Pres fetoimrs Code:)nin Con firs,tor'a Li- • ,,
canse law does not Ipply to an owner of pmpeny who Wilde or improv.nherson,and
wIs o core
nuscix for h prouith 3acwa conuaclo0s)licensed pilmm�t u,the contractors
<
nLa I
O❑welirme or
.B&P orth ... �
Deu _
`WORKR'SC MPENSATIONDECLARATON N O 26
0/. IhembY aRrm uMapanWY Of penury Odle al the follmvmg dal 1 .:' • ' , r ,
❑Inas aodwd'memw Section
37M fCommuo Ulf insumf W hatComf the
section as provided for by Section 3700 f she Labor CMC,for the per(osmsnco of she
WOfk fed W„IGh 11111 pelrlar is ISSY[d
❑1 have and will maintain Worgats Compensation Insurance..retuned by Section
3700of Ne LeWrCode,for the performanmofnhe.,it for which this permit is iaued. s ..
My Wooers Comncnaation Insurance,esrria and Polity number art: -j
Comer. Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS' -
COMPENSATIONINSURANCE -
(Thmsecli'm mend nor W cmmplemd fifth,pennil is faro.hundred donar,(SI00)
I crnmfy Wt in the Performastt ofJm work forwhich duspemvt is isaued.l shall-
not employ any person in say manner eco as no become subject o the Workers'Compen-
sutian laws of Califomii.Dam r
Applicant
NOTICE TO APPLICANT:If,after making Bra Cenifc m,of Esmond..,you should
Wcome subjecuo Ne Waders Compenra m provisions of the lab,Code.Y.mart - ^
forthwith comply wish such provisioner shit permitsucit W darned mvokn, r
Q
Z CONSTRUCTION LENDING AGENCY ti. •` s
Ifarw aRthi Na Ne r . .
Q ,. Y rc'secanawetion lending agency far she perfomwce of
the
work for which this Fermis is iavu Sec.309],Civ.CJ
E•I r
Lattices Name
CC, > lenders Addrtss
W Q .1 certify Nat 1 have re this I n d nae nut the above id("rmaniod is
. 'r
COmct.1"gra to comply with cis - .Nim".sed sum laws rtl.sing m
C.7 O building conspactimi.and hercb c crenutives of this rnymenurupos do, -
abovcmemiohed proPeny for In coon P dioses., - _
(We)"gra sin rave,Inde 'fy and kap humlcu the City of Cupcnino against
liabilities,judgments,costs and"Former which may in any way aceme
�F.r W in rn ¢of granting of shin p ie against id City
30�I�0. APPI,ICANUNDF.NSTANUSANDWli.LCUMPLY\VITHALI.NON. OIN •
V (,G SOURCE IIIiGULA"PIONS. -
Signamrt of Appbcam/Conharwr s nue ✓�e. V -
HAZARDOUS MATERIALSDISCLOSURE
Will the appliuntorf,art Wilding acapansi'me or handle hecadous madame' Re-roofs
as refund by the Cupenmcd Municipal Code,Chapter 9.12,and the Earth amt Safety -
Code.Section Z533(a)7 � Type of Roof• .
yer v
Will the applicant or future building Oceanus;use equipment or devices which All roofs shall be inspected prior to any roofing material being
. cwt heaardom Air contaminants as denncd by the Bay Ar.Air Quality Management installed. If a roof is installed without first obtaining an inspection
District] s
❑Y"tom' I agree to remove all new•materials for inspection. Applicant
Tuve r.sl the„aradum manuiaa rw7uircmenu undr,Cuptar 695 of the Cali. un erstands.and will comply with all non point source regulations.
rami.x. A saretr code,Sailam zssas.zssv and sss3a.1 andeRmw th.l irde
Oil n note sly have ten., tis my re Non iliry on yNe pans '
of ic„mb �I �j� eofaCe emof cupancv. Ioun ✓ n'
mlGa_
.Signature rofApplicant Date
onzndegem Deu '
All roof coverings to be Class "B"or better
'
OFFICE