00020125 CITY OF CUPERTINO PERMIT NO.
BVILVINGDrvISION. PERMIT CONTRACTOR INFORMATION:
QA 0OC22O12�'
RUILD�I U� 1 ^ I \ " -
SANITARY ND. , APPLICATION SUBMI AL DATE
s O NEIL'S AMC: I / ,eecc "' NIC CONTROLif
• ARC' ITECT/€NGINEER BULDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
ihereby dfrrvihw1amlicenseduMrprovisionsor Chapmr9(commencing w' .Job.Description •, q
mtw .with Station]000)ofDivisian3ofdu Bmin.sand Profrnion.Cosh.and my license is (��\�p ^'1�- '.
Y in full force uW effectLice1 w ear 9a r g ge
tup u D. Clan Conceal, W 0,�
u 3 u< Dau CPS DECLARATION
g O¢ .ARCHITECTS DECLARATION '
v�y,-' I underhand my plans mill be used as public in ids - -
a o 'Utereand Pmreuw
in
u�^_ OWNER-BUILDER DECLARATION
k >' I hereby from that I am exempt from the Comrutdr s becnae law for the
Ofollowing sen (Section TOII 3 Business and Profeuiam Cade.Any city or county
m which oriumeas a Permit in Conamrct,Ones,improve,demolish or miser any suvtmue Sy.'F loor'Area.- ZValuatio "
'peon t '. dao rcquirmthe appbcam for vucM1 pemutu NeengxA auumem
matM1 Iicesoodp nuantto me provisions ofdu Connutot's License Law(Chapter 9'
uommencmg wire Section]0001 of Dpviaion3of rhe Buuxuend ProuutonaCde)or -
that he is exempt theufrom ad me basis for the aU.gd exemption.Any violation of AP II tuber Occas•p�n y Type -
Secuon]0313 by any afflicam for a penm(mbjecu the suppliant to a civil penalty of `•J
,p t Co.man five hundred dollars(9500),,
1,as ownernrmeproperir.armremplayxxwithw.geanth.baofieompe...lot. . . .. Required Inspectionswill do the work,and the
structure 1,.1 intended orofferd for sale(Sec.7W.Buaixrs
and Piofessimu Cade:]3u Comeactor'i License law does rust apply to an owner of
property who Wiltls or improves thereon,and who d«.such work himself of through .. .
hi.own..Pray.A.pmvidd that such improvements are not inunded in offered forterhow me buil ding in. imovemem is sold within one rearof completion,the t •' - '
crbuildu will have the burden of proving that he did not build or mol mve for For. „
of sale.). .
u owner of the propcny,em exclusively convecting with licensed contracmn to' t
ons a the piojem(Sex.]Od4,Rusinaa and Profestlom Codi)The Contractor'.Li-
emu d«s not y us v owner of property when buildx or improves thertmm Old
whoc anhxn ora jeciewimacontrutor(sHicen.Mpunuantumer a=vactWs
.License V tgr-i� l�ll /Jx�
❑Ism.amp er r•,BAP Nis
Owner Dau q. .
. WORKER'S COMPEN ATION DF.CIARATION „ -AUG 13,2002 `
1 h.mby el0im under prnWy of perjury ox of ma following dedantiom:
❑1 hive end will meimun eCenifcam sur Copurnua sof-inauu far Workefe Compen-
sation,as provided for by Section 3700 of the labor Code,for the performance of the
work have andl ills pemdt is head. BUILDING .
37 1 have and will one,for Worrier's Cance ofhion work
for which
h required by Section • , "
My ofth6 Labor Code.forthsurance Cana of and
number this permit is issued +
Ca Waheks Compcnvtian Ipixunxe cepria and Policy number art:
Carries Policy No.:
CERTIFICATE OF EXION FROM WORKERS'
COMPENSATION INSURANCE
(This taction vied not becompludifthe Perim is home
-
hundred dollen U1100)
Icertify lbtintheperfortnenceMthe work forwM1ichthis pemdt isivud,lshall
n
it.
any person in any mommas.o n m become.mhjuno me Warkere'Compen-
"vnl-awaw.o(Celifomia.Dau
Applicvt -
NOTICE TO APPLICANT:If,alta peeking Nix certificate of th Exemption,Cis,You should
hecome b Comply
o the Wamkda Compensation din. pmvit hal of me hubor Code,you man
• 'foehwith comply wire such provisions m Chia permit shell be deephed
CONSTRUCTION LENDING AGENCY '
Thereby ofbmtmu mese isewnnmcuon lrnding agency fornhe performmen of l
the work for which this permit is iwued(Sec,3097,Civ,C.) "
Unice,Name
.(� > Landers Addreu
(TJ Q 1 certify the 1 Aa thio p "siren and sore mat me above infomuuon is -
sa7 Z correct.I egrce ro comPl w II ci
-A'_ry ordtnancee and sum laws relating m ..
building conswttion, hart y.J ho ser mesenwiva of this city roenur upon me
C.7 above-memioned props far inspfcfon purposes.
lWe)agr«to Ove,indemnify and keep fund.the City of Cupertino against
C V liabilities,judgmeias,cosu'aad expenses whichmay in any way sccroe against said City �"
�r k) in consequence of the gmnung of this permit.'
r "APPLICANT UNDERSTANDS AND WILLCOMPLY WITW1
H ALI.NON- INT ally I
t..) SOURCE REGULATIONS. c} I
figatuu ofAppliceHAZA DO Due
HAZARDOUS �Q�. ^, fit//J( ti(✓Cl.."gr " '
RDOUS MATERIALS DISCLOSURE
Will byteCuemor futurelp&l oe.Chantsureor hanNe health materia' Re-roofs
v defied by the Cupertino Mun22r'eeefffPal Code.Chnpur 9.12,end the Health and Safety •-. "
Corte.Section0yeo zss3xo] Type of Roof '
❑Yes. � No, p r
WIIth..pp0.h ter m( All WRdmgo cap�ntaseequipmentardevices whi.h 'All roofs shall be inspected prior to any roofing material being'
cin h.,onchmi.1,ComuW4myCdcfm.dbytheBayAreaAirQuaity,Management installed If a roof is installed withouf first obtaining an inspection
Pis le I a ree to remove all new materials for inspection. Applicant
❑Yes g
(have reaAs taunaiatryui mems seder Chapu6.93 of the Celi- Understands andwill comply with.all non point source regulations.
forma Ma1N ections 25 5.2 533 uM 25514.I undcn d mat if Opsbuildingdoe aemnm4 m nspomibiliry ren '( the ottv tofth.rryu mrnren ificre f
nature of7pplicant Date
owxr ore dz a Daie
"` • "�All roof coverings to be Class"B"or better
OFFICE ".
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