00020143 4
C_
UPERTINo
DIVISION • PERMIT /r^)p^.
CONTRACTOR INFORMATION: PERMIT NO..
SS V.V �O I �3
SANITARY NO. ION SUBMITTAL DATE
( LL x
NIC CONTROL#
INCER
PCO a g
r BALDING PERMIT INFO
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'�aec IO
LICENSED CO
NIRA
rn z CTOR'S DECLARATION
$S=c 'I hereby arrrm mat I ter raced oder Provisions of Chapter 9 apmmensi is 'Job Description '
"ryF5ly with Sa0on700o)ofDivision3ofine BusiavamdPmfnaionsCde,mdmylianse is - + ,�s
�Ya7� infullfmceaMeffect. ' t
,CwU LicenaeClw Lic.# New, +wo _C9T -; ( �qf CIE, '.
�'y Dale 717SDECLCmantracm, 3
ARCHITECTS DECLARATION r
F�Q O 1 underturld MY Plans shall be noted!u public rapids
°•n n i uc'issvd 3'mfcasronsl
PS_ OWNER-BUILDER DECLARATION' "-TT ll
1 hereby affirm that I em exempt from the Contractors License Law for the - - -
r c following mason(Section 7031.5,flue.and Pmfwions Cede:MY city aaunty -
t6u 3 m which requires a Permit ro cmnwce Wer.;mpmve,demolish, fie a si,any awcram S t Flo4 Area-
'prior loiui.auena.dmrequircs theapplicent for smh pemdlm Bleasignedauument q. '�Villllatlp{l,� a
Wl be is liamad Punuaat to Uu Provisions Orme Contractors License Law(Chanson,9 - /��J/I`/CEJ '
(commercial,with Section 7000)of Division 3 of me Busits ad Pm(wiaa Cede)m -
that he is exempt therefrom ad the basis far the alleged exemption.Any violation of AP umber r OccqancylType
Section 7031.5 by an,.,It.,fora fa mu subiecu the applicant m•civil pastry of e�'
not more men rive hudree dollars($500).
❑ I,apwnaprth=propRy,mmremplar awimwagamthirkpledmpenaan. Required Inspections
andl dothnsim"Code:
voumumsnaimm�hdoraw does W=(SaJOan..a,of - "
and propProfen..b Code:The Corel throrh License w law dos Iwl apply s lf owner Or '
his-we,will builds la improves leucon,aril who dies such work himself u m st fee •' " �' • "
his o e Dloyec,pmvrOd Ws such rmpbvemcnu art not inurdd a oRcmd fee a
sic. h th buildmg onmprovelanua sold within one yearofcompledon the
ow l ild iii hit",
burden of Proving that he did not build c improve for lute- 1 '
f sale)
f comer f dm P.,",em e.clusuely cpneml ng wim licensed cmtnetaa so '
c ns ct the protect(Sex:7(HA,Buamar and Profesdons Code)The Gp therom r s U- '
=tawdos ml y io an owner Of propemy who bu Idao Imp tMeon,and -
whocpntract rotate wW aeon mr(glcented punOnn
.O❑LlwanI neraom a . i. mCanenemen,
La "1 $
empt r Bk ml
Dau
+ • ' oI'f,r�//)
/Q I s d
WORKER S COMPEN rju,..DECLARATION -
1 M1 (fi
by rm under penelry a!peryory one of me rollowmg declarmioru, _
❑Ilia dw li me nwna Certificate orCovmno ul6insute for Workers Compr
en- 1
smon Provided f by S Uoa 3700 of me Labor Code,fa dte pMormaae of the ' •r
work for which this permit is Issued
❑1 have and will maintain Workers Compensauon Insurance.m reglad by Section
3700ofine EjdvMCode,fission doemarraa/ma work for which this permit I.issued. - a
MY Wprkm's Compensoi.lnsurmcecamm and Policy numberae: - -
CameePolicy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE "
or lw.)(This section reed not be completed iflhe perm,is Tomo hundred dollars($1DID) .f`.
I certify that in theperlormarice of the work for which this pentyl is issued,l shall
not employ any Person in any manner'so'as to become subject to UIe Worker'Compere-
sauna laws of COHIMM..Data
APplicanl
' NOTICE TO APPLICANT:If,aro-r nutting this Certificate of F,mmplion,you should
become subject to the Workera Compensation Purvis ono of the labor Crash:you must ..
Forthwith comply with such Provision,err this permit shall W deemed revoked. - -
CONSTRUCTION LENDING AGENCY 1,
I hereby of ion Chet them is r-ml.don lending agency for the performance of _
z the work fm olfl,h this permit is issued 1ec.3U9 Civ.C.)
['r Leaders Name
rf > Lender's Address
Lx7 0 I aRifY IF I love read this li tion d m Ihet the above information is
z correct.I agree to comply wim all m coon - sad nme Iowa relating 10
building conatmcdon.anJhercbya Orem rtp ve wi es of iiia cilymenur upon me
V above-mentioned property for inspafidn purposes. t
text [� (We).greebave,indemnify Nd kap haemlese lli=Cily pf CYa[RlnO ageiml •
V
inconacqundgmrnta,cpneand expenses which mayinany way acemeagilnn uid City . . - �. ,�
in equenee of the 8rmtin6 of Otis permit. -
.Fi APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH AI.I.NON-POINT
V z SOURCE Rf'GULA3'IONS.
Signature ofAPPham/Canusutor Dale .rQ A,,Xo 'tw cC err .
HAZARDOUS MATERIALS DISCLOSURE '
Will lhealmlicant or future building occupant surto,handle baeardous mmeng Re-roofs - -
,, a defined by the Cupertino Muni al Cde.Chupler 9.12,ad the lleulm orad Safcty '
Cede,Section 2553a.)7 Type of Roof "•
' ❑Yes .. a ..
willma.�E.wu this,b;,d;ng«enp.,areegp;;mo,ard.;ce,wh;ah All roofs shall be inspected riot to an roofing
mN(hceirOml.it east n.rlanta a{ n • p y, material beim
ndbythe Bay Asa Ah Quliry Mmmgcment installed. If a roof is installed,without first obtining,an inspection
"
District •
❑Yea, a , I agree to remove all new materials for inspection. Applicant
Iheve read the lu meunala uquimmrnu un der Chap ?5 al the Cali- un erstands'.and,will comply with'all non point,source regulations.
forma HuIN ly e, oro 5.10.21533 ted 25a3a,l un elawid mal if dr -
'build;ngdoes ole a havearena it is my rtsponaibilin�trindi( cpm - '•' „
of ma'myuir
owns pr, nd.gml , l,/L ate (/(/ Signature of Applicant Date,
All roof coverings to be Class"B"or better
' t OFFICE