00020122 `CITY OF CUPERTINO . - r - PERMIT NO,
BUILDING DIVISION PERMIT CONTRACTOR INVO'RMATIQN: "0 Q'02 Q / Z-Z:''.
BUILDING ADDRESS ,- - - . P `
l 0 I SANITARY NO.. APPLICATION SUBMITTAL DATE
3'--31-�
CONTROL#
Pk
AItCH Il I:C'T/EN(:INFF R,
IhNKI PERMrr IN.O
OO K Z aincl, s
e1'00 d
Kw
M.
!.C m + LICENSED CONTRACTORS DECLARATION '.
O Z=O ; I hereby eB1iN th licensed under provisions of Cbapt 9(t.-moa icing' `:'Job Description -
rr C w -with Sanon7000)afD nion3rf the Buvneasand@rfnun Cade arWmylisclila
in full forceand eyed
a.pwu 'Loc uClase !' Lic.# ` New -dour-crag 9a_rgi tj
a�3 I s- Del< Customer
C ARCHITECT'SDECLARATION -
f. 1 understand my Plans shall be used in public records' » * - •. k - i„ )
Li ed Pmfessianal '• '
.OWNER BUH:DER DECLARATION .v A
C G ra'I.hereby elTimt that I am exempt beat the Contoretion's License Law for.the
C follo n6 (Station 9031.5 Bmainasomal Peafeuiou Cox Any city or county i e, + 3
w 'm s•c_ -which
t ou,nes,a
. pe t m true after, demolish ramt"arYswre d .,P Floor Area Valu-
ation
.9.4,mas the pl" tf such permit toflea signed
sate cm )p
don'ss licensed pormnl m the provisions of she Contractor.License Law(Chapter 9
(commencing with Section 7000)of Division ofth Business and Prof ions Crack)or
..
that he' pt therefrom and ambnisfor thetllgediumlet A.Yvmlmis.of ' A'P�NNulnber x�V O cu ancyaType -
Scare 7031.5 by any applicant for a parent ubjats Ne Pplic.n e civil penally of 4 -
notmoreNenfv.1modreddiltam($5M) ' _
❑tial owner of Ju property or my employ N gunth I mampcnnJon. 'Required Inspections '
wdlxNework.and Neeizuaureunot mretaled Bred for el (Sec.]lN4,Buuneu :fie ' r1J-
and Professions Code,no Cmurecma License law does not apply to stn.1 of
+„ property who builds or improves thereon,and who does such work himself or through
his own employees,provided Nu such improvemems ere not,mended oraRemd for r -
"mile'lf,howrver.the Wddingrnmprovemenun sold withmone yeuof romplenon.Net 1. '-
pbuildr,will have the Written of,mom,Nal he did nm build or mepmve for par- n - - i
of'me.7
' 1,n owns of tI property us exclusively convecting withlicensed contract.to ,e 7
co ct Ne Pro)ea(Sec 7044 Bmituas and Profenrou Code:)The Contractors Li - -
cense Law does apply t of property( who WJde or i n -a,ther<rn and a .
wM1ocontme ch Prol ta th co_nvactors)Lcenecd pursiuntm Ne CanRutors _ a ''
Licmhe
❑,tem e n r$a .Bg:P
f/r
t Owne Dein t T/ � 1'f m
ORKER S COMPENSATION DECLARATION i t s •i
' 1 hemby ill mai underpenally of ofCo ent of Ne following dedarauom
.,Ms.and wie far
andi Oct f the Lab r Code,
f f W omm Co peon
satrk a provided for mi Sect 3700 of the labor Code,fm th peAonotaoice of the
'work Ghthspa i lied, i by�11j
❑1 have end will maintain Workers Compensation Insurance,u required by Section
3]00 oPNe LeWrCMe,for Ne perfsrmaae of Jia work for which this pcimil is inued. . •i+�' -
My Workers Compensation Insurance mania end Policy number arc:
Cartier:- - Policy No. ' a
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
" (TTis section need not be comPleicd ifthc pennitinforonchunxW xllusl5100) � .6', '�k .
' le cAifythatinthepeirommisaofNewmkforwhichlhiipemutisissued,lshell -
not employ any peieon in any manner so as to become subject to the Walkers'Compea.
salion Laws of Celifomin.Dau - .],•'
Applicant _ i a
NOTICE TO APPLICANT If,after melding this Certificate of Exemption,you should d - • `
become subject to the Worker s Compensation provisions of the Labor Code.you must
il F
finhinvois comply vviffi such provisions onM1 pe t shell be domed revoked
{117 j
Z v 'CONSTRUCTION LENDING AGENCY ) s
� O' ib by effrm Neth stmIt Ind gege,famheperromun id r'
.Z. the k for hicM1 this pemui is'a' (S J09),Civ C.)- +
lid
Lenders Name
Leaders Addrt
W
Icanif,dualhavorei� P li hand smte Nei Ne above mfomumim is
C4 A correct I Wee to comply wit 111 Nit, sd ty Nnuance acid tate laws telae g to
sU O ,buldingconstruction,coal his 1F erho representatives oohs tymemerupon Ne
aha e m t n'd property to 'k urpr esr'
-W.E.. (W) gree to cave,indemnify and keep
flab 1 ies Judgment,'rens an ue ch may in my weaCv'-sy. ufc e8pvennninsse adgeCnitey
mconugdofrM1e m(thistri
APPLICANT UNDERSTANDS AND COMPLY WITH ALLNON POINTe
'•lg7t SOURCE REGUIATIONS �F' • ,r�((�/((�y '-OolL
"
y
t -
'Signinum-f ApplicanVC valorDue ,..��e-
/Y'f
(� HAZARDOUS MATERIALS DISCLOSURE -
i WJli aWlmantorfummbuildngrcupemstomormon chazmdousmaunal• Re-roots ,
u d f ed by the Cupcm M n Code.Chapter 912,and Ili Health and Saf ty'
Cox s t p zss"(a, Type of Roof f •. ey ,
WJl,lhe pylic t wrebuildingoccupant use eq p t or deviceswM1i<h All roofs shall be inspected prior to any roofing material being
emit hazard un co um me as delbod by Ne Bay Arte Au Quality Management• installed)If a roof'is installed without first obtaming.an inspection
a ❑Ygg I a ree to remove all.new'materials for.inspection. Applicant .
} understands and will!c6rhply, with all non point source regulations.
Iha h a.,t.m oa �ntaun&r Chapur695ofi[ `Cali-
`forme H th y Code,Seen 23505.8533 end 255]4. understand that if tM ^n
Wildon does nenOY have eLNat it is my mponsibi' to notify Ne acupant
" '`of the quire 'ch list p ace ofa care f ups
Signature of Appllcant "' ' 4. " 'Date' -
'w" Owner rr auth W gent- f it Date
- All roof coverings to be Class B or.better'
OFFICE S ,