00020141 PER]dpf NO.
CITY OF CUPENO PERMIT WIN f e' ,
BUILDING
BUDING DIVISIOSIO N
BUILDING ADDRESS: ii
SANITARYNO. A3--31PPLICATION SUBMM ATE
s/C/l0 L.11ElOry'vy
0,NER'S AME: y
N/C CONTROL
:ND ❑
,RCHITECT/ENGINEER aUBbING„PRM •O
' S' A
LICEN
�«
•o°'z 1 hereby aRrmthesED 1 sto IOicrosWCurnd R DECLARATION
-Cof Chaper 9(commenting Job Description
u
s =�
.F ui to Ct10.TBOD)acDlvlsloa Sof the Business and Pmfasions Cade,"MY licenee is
i fall
.cane Class
add e6ect. �vVO J �h
License Class Lin.r ( i �q
3 uo3. N Dale Convuror YYY
O d ARCHITECT'S DECLARATION
0 0 i undersand in,plans shell be used u Public rcmNs
in Licensed Professional
y OWNER-BUILDER DECLARATION _
1-.1 1 hereby affirm that I am exempt from the Contracar's License Law for the
S>:O following reason.(Simian 7031.5,Business and Protectionist Cade:Any city or county
W3= which its audience.
u i v perm.w soma Chet aloe improve,demolish.1 m sepeir any summers Sq. F loot ea ` I Valyati
pdonoi[sinerial ,alsorequimstheapplicant for such pctors fileasignedCammrnt `�/JSr'y
that he is licensed Seems
tone of Division3 the Conusiness License law(C ode)in V V
(commendxempt Smtion]000)of basis for
do he alleged
cisandon.Any
Code)in APNN„rnber O cu cy Type
Net he is exempt therefrom and nr basin far the eileged emmptian.Any violation of Qfa J
Section]031.5 by any applicant pplict fara'MM subject.the applinnt to.civil penalty of
(00
rot mom than five buttered dollars(5500).
C3 I.sa owner of the property.or my infinite.with w yeti s neirsole compensation, Required Inspections
will do the workandne immune,is not intended oroffeend foruleSec.7W,Bursocss
end Profusions Code:The Contnctora Licerue Law does am apply to an owner of
property who builds or imryora thereon,and who class each work himself or through
his awn employees,provided dust such improvements are not hundred or offered for
We.If,howevrr,the building or ierprovcmmt is sold wind.ons yeeraf,h mpiddim,the
Wilder will have the burden of proving that ba did sot build or improve for ped-
5
ale).
1,a owner of ne property,am asmaw,mid convecting with licensednConnector,nei-
c s the r oj[nt(prop]Ey.a Bufleaa veld Pmfeaating Qede:)The natus LI-
cemelawdoesno pplytomof pmperty who bailda or impmce
vthmhvd,and
nib.O me orfhpmjecu winaroownernrshur(glieemadDurs. Cantnewe,
License
❑lam um d Sa.
Owner Date
WORKER'S COMPENSATION DECT.a In N
I hardy illfirm under penalty of Perjury one of the following Woncee.Co:
Lave end will tai by Section
37 tc of Comrnur Code.sum far Workers Compene
work
r hick this
p r by Smtion 3]00 of the Labor Cade.(or the perfcemana of the /O
rk for which this permit is ismN.
❑ I have and will mdintain W.rkeb Compensation Insurance,m required!by S...ad.
My ofthe Inbar Cede,for Imanammarmaofne workftawhich thiepermit is issued.
My Workers Compensation Insurance caand Policy mmbm ere:
Cartim Policy
CERTIFICATEOF EXEMPTION FROMROM
WORKERS'
COMPENSATION INSURANCE '
(]Tisstttinn need nm be completed iFthrpenrdtin farina hundrtd dollars(3100)
in leas.)
Loy my nota the my
of thework for whichtis permitisix%' dIpdshall
not employ any person in any manner so as m become subject to the Workeri Compen-
Ation Laws of California.Date
NOrn sot
NOTICE TO APPLICANT:If.er rafter making this viu.m.f O Exemption,you should
Most
become subject to the Warh r e Coons or this
provisions of due tabor Cade,you must
forthwith comply with such provisions or this permit shall be deemed rtvoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm thin nem is a construction lending agency for the perfonname of
the work for which this permit is issued(Sec. O97,Civ.CJ
e. Lenders Name
�Ia ' tanderx Address
F'� Q I certify that I have read this pl ti n a smtc net the above irtfomueon is
Cr mrtect.I agree[o comply with d1 ci cam mento and era laws rtleung to
r�7 z building cmnawntiom and hereby au Peace nm ivea of tNs city so enmr upon the
V above-mentioned property for impaction p I sea.
G r Fy (We)agree w nave,indemnify and keep harmless the City of Cupertino against a
� C.) liabilities,judgments.cosuand expenses which may in my way accmeegunnssid City _ Zy 5 JA
�y (c) in consequeme of the granting of this pemue
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
V z SOURCE REGULATIONS,
G�
Signature ofApplicantoCormartor Data ,�Yv7J NC1C(,;r
HAZARDOUS MATERIALS DISCLOSURE
Wilby t e li Or Cupertino Muni Wilding e.Chapter
r ore 9.12.handle Healts as and Safety Re-roofs
ss da,Sed by the Cupertino Municipal Cada Chapter 9J2,eM the Heels and Safety
code.serdan 25532(a)+ Type of Roof
❑Yes No
Will the applicmr or fu um building occupant use egWpmem or devices which All roofs shall be inspected prior to any roofing material being
emit herM,lous an commananu as defined by the Bay Arm Air Quality Management installed. If a roof is Installed without first obtaining an inspection
r " I a ree to remove all new materials for inspection. Applicant
0i ic❑@aot
g
th do ems¢dalamgwrtmenuunderChapwr6.93ofnrCali- Understands and will comply with all non point source regulations.
., Limits y ode,Secdons 55 5,35533 aM 25530.1 a mN that if the
bullditi Have.ten s itumyrssponsibility pfya upmeefthed dre iy�a eCenif yfy, Signature of Applicant Date
Owned age.[ Date
All roof coverings to be Class`B"or better
OFFICE