00020140 CITY OF CUPERTINO "r,"!- PERMIT/O.,
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
SANITARY NO. APPLICATIONSUBMITI'AL D TE
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,CI3ITECT/ENGINLF.R $ij DUjiDINO PERMIT INp
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o y i LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I am licensed under and
of Chapter n in,It...I. lob Description
y_m with Sectimo7000)ofDivision3of Ne Business and ProfnaionsCMe,and my li«nw is
in fall farce and effect,aLcese Class Lioocu N�'w i v o — c 'r J
q-a r
y\�
3 a N Da¢ Convector
a O< ARCHITECTS DECLARATION
[undercmbd my plans shell be used as public retards
.aF
�Ktt- Licensed Professional
u =m OWNER-BUILDERDECLARATION
F Z 4 I hereby affirm the,1 am exempt Buenos Commerce,License Law for the
SSp
Todussid, 7031.5,ct,Me"impr Professions Cods:Anycity orcoonty
titer 3 which requires a permit ro torea de alma improve,demolish,or repair enY svunurc
pdorm nsisconlo altranomireslhcappim.fthr aucM1pcmdt micense aw(Chapter9 Sq. . F1oo, r�Area 12 v at' n
(cot hale licensed pSectio 70the provisiam of me Contracturess nd Proe Law(Chapter
or I �t
(cat he
(commencingwith
an M basis for
of meeged Whiston,Any
Cade)m Alger Occu ant e
That he is exempt therefrom and rhe beers far bj alleged exemption.Any l violation of ^. ^ ,sem. p y Typ
Section Th 1.3 by any applicant for a permit rmbjccv to applicant to a civil penalty of '/C/i/1/C/✓'-1 ]`+Jz.,
not mom Nen five hundred dollars y empl
❑ 1,as owner of the pmpcny,n I, employees with wages r ale(Sec.compen sines Required Inspections
will Pr f e work,and me structure is erimmoded s Law do far sale(Sec.tan Business
end e,t,who
Cade:The Cos There
s License law Jas not apply s lf owner of
his o ny who builds or impravth n such i,and who does encu work himself ar mml for
his own employee,prrrvided than such improvements ere nm imendW n oRerW for
sal If,howevec Mebuilding orimprov em is sold within one year ofcomplexur,the
er-builder will have lee burden of proving that he did not build or improve for por-
e of aele.),
r of Ne prapeny,am exclusively convecting wire limsed convacton to
onso et me project(Sec.)1TOU Business and Prefamiom Code:)The Convenor's Li- /
ceuxe Law does nut pply to an owner ofpropeny who builds or improves thercmu,sed
whocontract or Ehprojenswimae nlist ar()licenaed purmmmthe Conmacmrs
License ,
1 em amp d ee. ,B&P for n
Owner w Dam s Is =0
WORKFFR'S COMPENSATION DECLARATION
I hereby offirm under penalty of perjury one of she following declaratiom:
have and will maintain a Certificate of consenuo self-insum for Worker's Compose.
n.ea Provided for by Section 3700 of On Labor Code,for the performance of the
work for which shin permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3700of me/.ebur Code,for me performance ofine work for which this permit is issued.
My Workers Compensation lnsurance carrier and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectino meedme becomplewl if me permit is faronennMrW dollars nIN)
or leas.)
I cenify that in the performnceofThe work for which This permit is issued,I shall
not employ any person in tray manner w as in become subject to the Wohere'Compcn-
action Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making do,Cenificam of Exemption,you should
become subject m me Workers Compensetior provisions of me Labor Code.you men
fonhwim comply with such pmvisions tor This p<.I, hall b<deemed revoked.
CONSTRUCTION LENDING AGENCY
O 0 I hereby affirm that Nem is so Non lemling agency forme perfmmunce of
Li
4 work for which Nis permit is rest d( c.3097,Civ.CJ
a ,,,a Lenders Name
tender's Address
W A 1 cenify met 1 have mad p tic tit xute that Ne above information is
men.I agmc to comply wIN of city nd o ry rtlinencee and nam laws mlot"to
z building construction,and hereby mhorize representatives of this city to enter upon the
f..l ebovs.memioned prapeny for inspection purposes.
W Fey (We)agree m cave,indemnify and lamp hinnies,the City of Cupertino ageimt
O (J liabilities,judgments,crisis an
rsand expenses which may in y way ecmea
cgeinn said City /Lw�
>i (r] in tenses,ud a of the granting mis permit. //��3
P- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
U z SOURCE REGULATIONS.
Signature of ApplicaWCommcmr Dam •�- P�'�"-v�.7 yl.Lr(,.ta y1 J
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building occupem store or handle hazardous material Re-roofs
as defined by the Cupertino Mu cipaI Code,Chapter 9.12,and Ne Health and[Safety
Code,Section 25532(e)? \r Type of Roof
❑Yes No
Will the applicant or furore building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being.
emit hamrdous air contaminants m defined IBM.Bay Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
v"ro Yes yo I agree to remove all new materials for inspection. Applicant
IIT d Iscmdouamaterial,requirements under Chapter 6,95 of Tom Cali- Understands and will comply with all non point source regulations.
fomes Hen
Ail,So Code,Senions 5505,M533 and 25534.1 understood that if the
building he dyhaveaenun,thotit ismyrcspomsibil' mnmifylheoccupamt
of Ne ircme ih un et ie uewe ofa 'fe Oct y.
w '
OwnerSignature of Applicant Date
o n rma ant Dam
All roof coverings to be Class"B"or better
OFFICE