00020124 CITY OF CUPERTINO '- ll��H�i ,$8� )' `"' "- �*, "�; PERMIT NO.
BUILDING DIVISION a 0y,�It, dT 1? s r 1' I r
PERMIT .Q x g C-) 002 V 7 Z
BUILDING ADDRESS:
G+ v gANTfARY NO. APPLICATION SUBMITTAL TE
OWNER' NA EE: . a sy
sly I C N/C CONTROLM
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CHITGCf/ENGINEER "J -coy ;5�.- 'BUEP RMITIINPQ(, 2
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i LICENSED CONTRACT'OR'S DECLARATION
Z—0 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
m F m
full
to nnande effect, aion3ofte Businexsend Pmfeasions Code,end mylittnre ie
in full force and.Ben.
St Dino Clew Conor New A / ..ro�;r.� Ger 9qm ,
3 u w Det= Lie.0 cmr `I\r�/V
u_O< ARCHITECT'S DECLARATION
1 understand my plans shell be used as public records /
E es� Licensm Pmfcaslonal 11 J
w_m OWNER BIIRDER DECLARATION Y/
1—z T I hereby affirm that I am ascend from the Contractor's License Lew for the
f_=O fallowing reawo.(Section 7031.5,Business end Professions Code:Any city or county
w 1= whim mquims a permit m c.mwn,ehcr,improvq demolish,m repur any swnme
°'3m pnor 1.its kmans.also remoc,the.pplimetforsuchpermit tufleesignWnstemenl Sq. Ft. nor Area Valuation
,het he is licensed pumm ct a the provisions of the Contractors License Law(Chapmr9
(commwcing with genion 20(ID)of Division]of the Business and Profenionn Code)m
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ` AVurnberr ^ Occupa�n y Type
Section 7031.5 by any applicant for a permit subjects the epphrmt to a civil penalty of .X7 (Q �
Qt more than Ave hundred dollars($5000.
4an owner or the propcny,or mY omployees wile wagesu their so le compensation, Required Inspections
will doth.work,and Ino nmcture is not inuded m o
nffereness
d for sale(Sec.7194,Bmi
and Professions Cade:The Contractors License law does not apply no an owner of
property who bull&or improves thereon,and who does such work himself or through
his own cmployos,provided that such impmvemcros sure not intended or offered for
sale.If,however,the building or improvement h sold within one .of completion,the
owcr-builder will have the burden of proving that he did not build or improve for pur-
e of sole.).
I,u owner of the pet,704 em exclusively convecting colt 11Ceneed wntsanms ro
c,the o.ran(gee.]094,Business end Prirt,who bo Code:)The e.thectMs nd
cense law does not p ly to m ownm of propcny who builds or improves thereon,end
who contracts far s c projce with aeon tma)licensed pursuant m the Crummurs
License !
❑lora amp r ,H& for ti
Owner Doe v. n
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ane of the following declinations,
haveend will mainum aCembouneofCm errom relf-insumfmWorkersCompen-
on,as provided fim by Section 3700 of to Labor Codc,for the perfmmance of the
work for which tis permit is issued.
'❑I havo and will maintain Worker'.Compensation Insurance,as required by Section
37IlOof the Lobar Code,for the pofformance of the work for which this permit is issued
My Worker's Compensation Insurance.artier and Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This soden need nm be completed ifthe permit is fmon,hundred dollars($1(X)
or less.)
I ttm ify that in the performance of the work for which this pemd,is issued,I shall
not employ any person in any manner so is to become subject to In.Workers'Compen-
in ant Laws of California.Doe
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Enemptiw,you should
become subject to the Workers Compensation provisions of the Labor Coda,you most
forthwith comply wit such provisions or this permit shall be deemed revokW.
CONSTRUCTION LENDING AGENCY
0 I hereby M.that there is,....ruction lending agency for the performance of
the work for which this permit is issued(Sec.3191`1
09,Civ.CJ
t„y Lender's Name
a > LendeYs Address
Ga I certify that I have read this ppl•alion nd to tat the above infomuti.is
Qa A correct.I agree a comply wit all ei an con
y o es eM aura laws minting m
r7 Z
building con.Lroodmiand hereby a rep a til ofthis city wenterupon the
V
above-mentioned propcny for inspe ion pu
W E~ (We)agreem nave,indemnify andkeep hsay in an the City ofea,maCupertino against
V I.oione,judgmenu,.minond espemmswnich may in any way acemeegainst said City (J,
�., 0.W m consequwcc of the gmming of tis permit. T
FI APPLICE REGNDI[ONS.DS AND WILL COMPLY WITH ALL NON-POINT
V
SOU RCE REGULATIONS
Signature mApplicant/Commoor Data
HAZARDOUS MATERIALS DISCLOSURE
Willie applicant or futurebuld.,occ.,artsmreor".We hmmtlam material Re-roofs
o defined by the Cupenino h! i eel Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(,)? Type of Roof
❑Yes
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hasardous air conumltunefsned by the Hay Area men
Air Quality Managet installed. If a roof is Installed without first obtaining an inspection
°``"
❑Y o g 1 agree to remove all new materials for inspection. Applicant
1h 6 "cou materials requirements under Chapter 1,15 or the Cali- understands and will comply with all non point source regulations.
(ronin H i& a< y m7e,Sections 25 05,25533 end 25534.1 undmsund to if the
boldin does no nil havicete sJ{4,titismymsponsi 'lit to naify ocoupent
of ie tore hi ygt be t yens,;ofa
Owner pr,tienred agant `'`�"� Dau Signature of Applicant Date
All roof coverings to be Class"B"or better
OFMCE