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00020121 CITY OF CUPERTINO - PERMrr rvo. Bott,DINC DIVISION PERMIT CONTRACTOR INFORMATION: • : O O 2 / Z I BUILDINGADDRISS: • .. ' SANITARY NO. APPLICATION SUBMITTAL DATE O NER'S 'AME: ♦ - —'N ' —99 N/C CONTROL# PI )NII. n. - s r ❑ .. Ir • ' ARCHITFCrMNGINrs17R Gly'', - RULDING PERMIT[NFO 400. Z o y 2 LICTNSED CONTRACTOR'S DECLARATION O Z_G I ha aby affirm that lam licensed under Provisions of Chapter 9(commemins Job Description . r,4��u 'with S.Ii..7M0).fDiviiku.3.ftba B.a....sanldproliced.&Cade,and mYlianse is i =o � LicenothAlae Class a cHca U,# ' .�A� •-�/—` , ... . ! 3 u.�, Dare CMuacwr _ .�� V yr \ ©ur�-•c'sarc ►rq t-.u O g ARCHnELT'S DECLARATION o, '1 understand my plans shall be usd as public records ce i g e Licensed Professional 0 OWNER-HUH-DER DECLARATION C?a 1 herebr aRrm.hat 1 am eaempl from the Contractors License law for the - m following reason,(Section 7031.5.Business and Professions Cade:Any city or county which requires.permit to secede),they,improve,demolish,or repair any structure 5 FI JOOr Arei1•7 prior to its issuance,Also"once the applicant forsuch pcmut to file a signed summenl q. Valuation" that he is licenrd Pursuant In the provmdm 3f Ne COmaters License Law(Chapter 9 •• Z 3 O O V (commencing with Swtlon 7")0oXvision 3 of Ne punishes and Profeuiom Code)m dal he is esemPl therefrom and es,bus for the.Vega exemplion.A.,viola..of APN Number Uccu ancy Type ' Section 7031.5 by Any applicant for a pemtit subjects the applicant to a civil penalty of not mom than five hundred dollen(SIM). - ❑1,zed owner of Ne propeny,mmY employece with wage,eatheiraolecnmperuNni. - RegDlred Inspections will do Ne wmk,eod the.wnum is mtinteodsoro0crcd(molt lSa.7D14,euaimu and Profauioru Cade:The Contractors License law dor mapply to an owner of property who builds or imPmva thereon,aced who doe.such work himself or duouQh his own employees„provided Nat such improvemears use not intended or offeta for n s - ' saleif owever;N<buildingorimprovcmrntia told wiNinone,aero(completion,rhe •a _ ' - owd - ilder will have the buNen of proving that he did not build or improve for sur- ofWe.l. I,as owner of the property,are eulusivety contracting with ficenls contractors to co et Ne project(Sed.700#,Business and Profassiom Code:)The Conuecous.l.I. Genre law does nate ply m son owner of property who build,or improves Hereon,and whoconnect ku pmjecu wish a conurector(q licensed pursuant m the Contwtoes License V r ;'./. !�.�r( • ❑lame rope Sec .Bhp for this rrasan G/O - \ YOwner Dae _ > - WORKERSCOMPENSATIONDECLARATION - lherebys irmun4rpeneltyofperjtuyorraofthefoliming aclaruiom - t - ❑I have and will business a Certificate ofConsent to self-insert for Wohces Compen- #• union,as provided for by Section 37W of the labor Coale,for the perfortreae of the work for which Nis person is issued. 0 r ❑1 have and will maintain Workers Compensation Ireunlnm,as required by Section 37M.Fthe labor Code,for the perfonmame of the work for which this permit is issued r MY Worker[Compensation Insurance tamer and Policy number are: Cartier. Policy No.: s CERTIFICATE OF EXEMPTION FROM WORKERS' - ' COMPENSATION INSURANCE ., (This section nod nor becomPlered ifthe Permit is heretic humlred dollars(SIM) - r or I...) I catifY wt in the perfo.of the work for which this Perrdi,is mued,I shall rot employ any person in any manner so as to become subject o the Wareere'Consul noon Laws of California.Date Applicant ' NOTICE TO APPLICANT:If,after)raking this Certificate of Exemption,you.bould become subjecsto the Worker.Comperiscom provisions of Nc Labor Code.you foMwith canply with such Provisions or this pelmll shell be deemed revoked. CONSTRUCTION LENDING AGENCY 0 0 p IherebYhffimthetthereisaconnmetion lemling agency for the performance of IZ Ne work for which Nis permit is isen (Sec.3097,Civ.C.) res Lender.N. a. > Lehhe,Address a I I - - ' W Q 1 cmify nits 1 have tl”' 4 Tic Nd 6101,Nat the above inromuli0n is - nrtct.I agree to comply w 11 ci y a odinence,Md some news rcblinB to OIbuiltlina<onaWcdon.and he by o u pre, tativa ofthis city to enter upon the r above-mentions proKny to nspecu0 pan as. ked 'e. (We)ages m rove,in ify a keep hamrlea the City of Cupertino against - f�0'' V liabilities,jW,..ts,cats and expense,which may in any way seen,against said City F+ 0- to T PLICANT UNDERSANTS AND WI I.1,COMPLY WITH ALL NON-POINT V z SOURCE REGULATIONS. l'./ r Signamrt of AppliceHAZARcror, Gone ., �1 Y1 iY��t Wsr '1 ' 'HAZARDOUS MATERIALS DISCLOSURE Will de,.,licamorfPmreWilding necupant.mrcorhadle ha,Wousmaleriif Re-roofs as defines by the Cupertino Mun' I Code,Chapter 9.12 sod the Health and Safer, tae,secant 15532(.)? of Roof ' ❑Yes•. No Will the applicant,. fu tort building occupant use equipment or devices which All roofs shall be inspected prior toany roofing material being emit hewdoua air conlaminanaas defined by the Be,Arca AG Quality Man.gemenr, installed. If'a roof is Installed without t-first obtaining an inspection District? ,- I agree to remove all new materials for inspection. Applicant ❑Ye. d I 've re' the haws ane nutenaly reyuimments unser Chapter fi.93 of lsc eau- un erstands and will comply with all non point source regulations. - -Fom� 1 Illy code,sad 25sos,25533 and 255M.I urdwsuM that if the hail d s currently t t,rhuit is my msronsibiliryedify theampMt of req naaw`ch P tierce ofa CM �fpa�unwy,.. Owner or ouNo edegeor s Date Signature of Applicant ' , - Dale All roof coverings to be Class `B"or better OFFICE .