00020116 r
CITYOFCONTRACTOR INFORMATION:NO PERM N0
,. . PERMIT . ! r 2 CQ
BUILDING ADDRPSS:
I0 - _ SANITARY NO. APPLICATION SUBMITTAL DATE
(N.4NFIR NAME; f
L NIC CONTROLp
P ON^
iv—
ARCaiTEt, :NOINEER - .. NULDINGI'ERMITINr0
r
LICFbISED CONTRACrOR'S DECLARATION - ` i
o o„_? I hemby aRnn dear I thn hanged pros pioNuens nr Chaplm 9(enmmeaing Job Description
�� iN Sdtion]I%IO)of Divisim3of Ne BusineasWRofeviom Code,aM mylicenmis `
,Y7 in full force and affect.
yop°j u, License Clesv _ Lidas
ard.r,.• 1'oVr—.`+ar . .�a ra �l.
3 C v, Due C'S DE os, s.
C tS O g ARCHll be un S DECLARATION v
v�j, 1 undenrW my plans shall be uaetl es public rtcdds
z<
SM
Licensed ProfeuiosW
OWNER-BUILDER DECLARATION '
0,y 1 maxo .Rem on 1 em exempt from the ContrmtCre License Law for the "
r•.O whichfollowing,dre,.(Section]03LSBmide, and vin.iom Code:Any an or county o-
G$ which its ims n permit m cowwct alter,improve,demolish,or eapsig any srmcnue
- � Sq.Ft.Floor Area ' _V ]nation
-
pnw m its ismana,slur mquims the vistomam far each geoid m fila s signed gatemem �5
(thint coh ming iffiS uamto N.pmviaima of the Conmadw'a License iw(CW c)or - 0
doom he
�xe with5 eons anal)No basis
the al Buaineu and Pro Any vi Code)of AP Number Occu 'Inc Type
Set he is<ssmpr tauefrom ant dw aura fits be alleged exemption.My it pe aan of Y YP
Section IDJL5by any dred d.4t(waPermit aublecb Bae applicant toacivil pevlry of 3 �8 -
d mom man f o hundred dollen -
❑L.thewowner of Nethe..property,wmY employees with wages as their compeuaum. 'Required Inspections
'- - will tlodeework,and Ne sheaths item'.Ud.d Law do,,
91W6, ots,of _ _ r
and Bofnhe Cad.:The os.tb ora.end w Law does raw apply m an owner of
progeny who Ni1N newircel m thsuch end who does w,en wok himself or Enough
his own however.
provided met such imp is sold ts thin raw in sur is or offered!for '
sale.IL owea6 Ne Wilding w improament is sold within one yearofcorsmleden,dee {
o Idu will Wve the burden of proving Net M1e did nm build or improve for For-
so '
I, I a cr of dee progeny,em exclusively conducting ward licensedcontractorsto
I Ne projea(S ]D14,Businessend Rofnsions CodeO This,Coneaaore Li.
ectad w duns urn sp war.wner of property who builds w improves Nereon,and •. li•�n p,j� rs r�
whocm t,f an, jecuwiNacontsacmgglicenaaxi pursuavtto the Convectors tl'� II tJ�zf'aNs t��i
Licmu law n
❑lam cx Pt -
.BAP a n
OwnerData AUG 0 1 2001
WORKER'S COMPENSATION DECLARATION -
1 hereby affirm wMei penally of perjury one afdm following declarations:
�.Ihevx and will,far
eCe rs 37W of W,Laor Coda,mmforindormance of the BUILDING "
non,u provided fw by Section 3]00 of sW tabor Cade,for dee'pertomunu of the BUILDING
V7 ,
k7wok for which mi.porous is issued,
,]1 have and will msinum winder's Compensation Incandesce.u"aidd by Section -
37W of the labor Cole,for Ne p6lormanceof ds,wwk for which dens Permit is iuved. -
MY Wokers Compensation Insurance indoor and Policy number am!, -
Camer: Policy No.:
-CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
India section need nor W completed if Ne permit liforoechdidetd dollars($l oor leas.) ,
Imnify Nainduperfo cofNewwtforwhich Nis em tisimu .iaWll "
no employ any person in any manner m as m barons,subject to Na Wortma'Compen-
sation Laws of California.Dau - -
Applicmt y.
NOTICE TO APPLICANT If,after matin,dei,Certificate of Exemption you should a,
hm
eme subject to Ne Workers Compensation provisions of Ne Labor Code,you must
roMwid,comply wide such provisions or this pe.It.h.11 be lamed revoked. -
CONSUC`oON LENDING AGENCY
0 fRI hereby aRint dust Nete isecannrucdon leading agency for Ne performance of r
tW wwk for which Nis permit is iasud Igo.3097,Civ.C.)
to Lenders Name-
(� I[�'
Lenders Address .
W 1 cenity Net 1 hive rand Vid
',to m ata Net the above infordW tion is -
�+ correct l.gra ro comply wide ala ry cine and scam law1 mlating m -
a z building cowuacuon.thW hemby - r m ofthi,citymenurupon Ne
eaove-memionW POIs,nY fa ins le.
Gz (We)agree m cave,indemap harmless Ne City of Cupertino against
O V Iiabilidae.judgmmu,costs We.pames which may in say wayaecmee,ainst said City
^�. W in consequrnce of th.Brome,of this permit
[r C4 APPLICANTUNDERSTANIJS AND WI 1.1,COMPLY WITII ALL NON-PUNT -
U SOURCE REOOLAI IONS. ,
/a
Sigduurc ofApplicmJCARDOr Dade Q.e %�iv7,7 ti•(JCG ,
FIAZA fours, MATE RIALS DISCLOSURE
Will t e CtiporuakMtirRNildCoda.Cgmumrt2,handle hersrl and.Safe,, Re-roofs
C definect io dee Cupenin Mu'ipa Coda.Chapter 9.12,etW dee H.aIN and Safety
Cole,soden 25532(.)?yes T e of Roof .,
YP
t /lorsl�r'a All roofs shall-be inspected prior to any roofing material equbeing
Will the applicant future uture building occupmt use ipment car devices which
out haardous ,air contammons ai defined by tW Say Asa Air Quality Manfirst installed. If a roof is installed without obtaining an inspection
Vcn No d I agree to remove all new materials for inspection. Applicant
❑ _
lmIhave nddteM1 msv m niam ntsaM,Chep r695efN Cvi- un ersfands and will comply with all non point source regulations.
is Nealth A a ty Sections 235 5,25533 and 2530.I understand Net if dee -
uildin8do-+ c rt hevc au:ne Niit ismY respdnaiNli1, ify Ne«cupms
or rcgbtrc u t d aCenI o of .�y}�
UO Signatureol'Applicant Date '
Owneronu zed egem ns, ,
All roof Coverings to be Class"B"or better
OFFICE