00020137 CITY OF CUPERTINO a PERMIT NO.
BUILDING DIVISION PERMIT iCONTOCTORINFORMATION ..
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BUILDING :
l�ADDI2PSSs S. Hqnev Ave- SANITARY NO. APPLICATION SUBMITTAL DATE
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NIC CONTROL#
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'HITcLT/ENGINEERSUI:DING'PERMIT IN
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F-u�i LICENSED CONTRACTOR'S DECLARATION
iu,M I heuby.firm now 1 ser licensed under provisions of Chapter 9(commencing fob Description
o, with Section 9000)ofDivilbm 3afthe Businussnd profusions Cade,and my license is �`r �]
y W, in cls and eRem N�w o --`A--'ll ��r U
3 i U ucenu Class lie.#
pate Contractor
u O a ARCHITECT'S DECLARATION
vW j, 1 understand my plans shall he used u public records
Licensed Pmftions.]
OWNER-BUILDER DECLARATION
?4 I hereby off W that I nm exempt from the Connectors License Law for the
O following reason.(Section 1031.5,Business and Prof onions Code:Any city or county
w 3 m which"arms a Permit to comwct,alter,improve,demolish,or repair any wanton
prior to its i.wuaom,Man minim the applicant for uch permit to file a signed statement Sq. F loor Area � Valuatigt1
Nat he is licensed pmmam he the provisions of On Conwnoee Ltunse law(Clupte,9 (�
(commencing wish Section)000)of Division 3 of the Bull...and Profusions Code)or
Net he is exempt Neufrom and she basis for the elleged exemption.Any violauan of APN'N—umber Oew,pan Gy Type
Steffen 9031.5 by any applicant for a permit subjects she applicant to a civil penalty of v f
not more Nan five hundred d doll (5500).
El 1,as owns,of the mc,amty,m any employees wish w.gu as Nate vele eampealsomm, Required Inspections
will do Ne work.and Nestmnum is not intended oroRmad fertile(Sec.7W4,Busing,
and Professions Cade:The Contractor's License Law does not apply to an owner a
propony who builds or imp ova thereon,anal who dean such work himself or though
his own employees,pmvidnd that such improvements ars not intended or olfued for
We.If,however,she building or improvement Is and within one yearof completion,Ne
-Wilder will have thc burden of pm,ir,Nan he did not Wild or improve for par,
ofaale.).
Las owner of the property, m areclusively mouuung with licenand conmctm to
w n the project(,Sfc.9('4,Business and Pretentious Code:)"a Caricatures V- /
eau law does nut Ply m m Owner Of property who bail&'rr impuvm&wean,and
onve
who cct hpmjects with a conv.ctods)licensed pursuant to the Convectors
License La J
❑lame mut el se .Bk for Nl _
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aRirm undo penalty ofperjury one of dm following dedantion.:
have and will matmaina Cenificam of Consent o self-inswe for Worker's Crispest-
„ pmvidhfor by Secuon 3'100 of she labor Code,for the penfomunee of the
ork f forr which Nis .it is termed.
❑1 have end will muinlam Workers Compem,don Insurance,a"uired by Section
39W of the Labor Code,far the performance of dm work for which this Permit is island.
My Worker's Compensation Insurance carder and Policy number art:
Cartier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nil section coolant W completed if she Pmml is tome,husuhcd dollop($100)
Or less.)
I centfy that in the perfomence,of me work for which this permit is issued,l shall
not employ any person in any manner so as to became xubjeu to Ne Warkera Compen-
sation Law.of Caltfomis.Date
Applicant
NOTICE TO APPLICANT:If,after reeking this Cenifcase of Excmpuon,you should
become subject to Ne Workers Compensation provisions of the labor CWe,you must
Forthwith comply with such provision,or this Permit ball W dnrmd mambo
CONSTRUCTI N LENDING AGENCY
0 I hereby affirm that theaint c nmcdon lending e,or,fon he perfossswce of
r ^ Ne work for which this person is lame I(Sec.3099,Civ.C.)
E,r Lenders Name
W Lenders Addrtsx
W G I cenlfy Nat I have r In, up li ye and ante Nn the above infomutinn is
corrtn.I egrce m comply wit e y d o Y.M.end m¢laws reining to
builtlinp consWcdon,enJ hart y amhot u rtprtuntnivan of this airy to enter upon Ne
f..) 0 abovememionnd proPeny far i pccuon umn¢s.
WF (We)agree resave,indemnify and keep hsrmleu she City of Cupertino against
C C.) Iiabilm ,judgments,cmtamulexPenus which may in any way.,.a arm, aid City
>rW inconsequence ofthe granting ofthts permit.
-r
r91- APP:.ICANTUNDDLL
EItSTANDSANWICOhIPLYWITHAI.LNON-MINI'
U z SOURCE REGULATIONS. J/
J v 1
Stgnam,clfhe.,]HAZARDOUS
Dere wL'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding receptors sena or handle haerdous material Re-roofs
as defined by the Cupertino M &pal Code,Chapter,9.12.and the Health and Safety
Code,Secaon 25532(x)9 t Type of Roof
❑Yes No
Will'he.pplicsntarfuture Wilding occupam...cl.i,nnamordevices which All roofs shall be inspected prior to any roofing material being•
emty Moreau a'u contamtn.n defined by she Bay Ama Air Quality Man.gement installed. If a roof is installed without first obtaining an inspection
Afti ❑Ye, I agree to remove all new materials for inspection. Applicant
` 1 �v� she haw ous tNledale nquirttswty under Chapter 6.95 of that Call. Understands and will comply with all non point source regulations.
fame. .Ilh Sxfny CWe.Sad m 25515.25533 and 25531.1 an erm nd Nan if the
Willi Idea "of urfbntly Wv e¢ anal.Net it is mY tuponxibilirytnoti(Y she recuPent
ofN rtyui h' hmu nu/aumen of a Ced .1
D upeq )
m q /fJ
y j Signature of Applicant Date
Owner m aushonred,ce, Data
All roof coverings to be Class"B"or better
OFFICE