00040035PERMIT NO.
CITY OF CUPERTINO
1. �''(jN rCTOR 71t��'Irk�N - '
••;,BUILDINGDIVISION ;: xPERMIT" QDD�-0035'
4I BUILDINGADDRESS'.
✓ SANITARY NO , -4 APPLICATIONSUBMITTALDATE
OWNPR'SNAME�
". ° Lhrr� ❑
'CONTE L# N/ir ir '
9 p�
PHONE.a. W 11 I9 'SU®rI.� _
- ARCHITECTIbNGINEER,1�.. _� Il-blO
} O'PHRMITi F
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provinces of chapter 9(cornmencrng d - JOb DescriptlOn '
cr, Cro with Souon]000) ofD son3 fthe Buses dPrrf uians Code abd mYlice y, t -
4 infullformandeffea - f' n t +
E Uceme Class Lich
paj',; lu- Dem DE
COn CL
F u O < + ARCHITECT'S DECLARATION
turbotan
dmyplm shallbetiredes Publcomoda t
Licensed professional r a -N ✓ i • •.
OWNER BUILDER DECLARATION '
Z 4 1 hereby a(Sem that I em eaempr from the Contract Anse Law for the
5 O following (gat 7031 5 Bestirs andPro@serone CWa A Y city or rnu ty
- > a
which req sea.perm t to construct, alter, Improve, dm ahm nr mmur any stnmmr , a Sq. %/Floor Area Valuation = -
pal tot . ,dl ranimes be applicant formch persnin fl esgnN xmt.t ,. cfv� taA 0�
that he is hossaedpmai a Chep v sof the Camomile.License Lsw(Clutpter 9 (l .i(
(comm nwngwlNgau ]000) TD bn3o(NeBuOneeaandPm... dacod i " APN Number. Tv - OCcu ane e `
bath s exempt therefrom and the mass for be alleged exemption. Any violation f P Y r�'P
Semen 7031.5 by any applicant for a permit subject: the applicunt to a civil penalty f 'DOg, ,• .5 4
'� t mom than five hundred dollars ($500) i '-
I,isnwncrofthepmlany.nrmyemployeiswdhwagesaeth solceoin emmrn, , I' ^ Required Inspections t
'will pr ofessions, and the he Contractor's
sial I.aw dos net applyto.;Business 1 �' I '
1 and erofesuob Cade: The Cont theca , Lt.. a Law sacs ala apply t do owns gh
his own empl W ills orvidestimproves thereon, pr who dose sono week himself m rhmugh - c
his own emPloYeis, provided that such improvements ve'nrt immmded'm oRered for - � �r • It.
,
•sale•I laoweveelhebuddmgoden aflement is sold fid a., dear inup
Wilder will have the burden of proving Net M did not Wild or improve fm pun
1, as owner of the properly, am exclusively co tee ung with licensed cdntncme, to •' -
t be project (Sm. 7044, Business and Frofeaamns Code:) The ContractorsU
. la
canw does not apply to an owner of property who Wilds orimpruves thereon and -
k who contracts for a Iects with a contracmr(q licensed pursuant m the Caterane. -WOO
Llan. Law.
Ism axe pe Sec. ^ B&PCT Nis mason ,F®�• A
1
WORKERS COMPENSATION DECLARATION - -
1 hereby offirms under penalty of perjury one of the following dodarso om� -
�.. ❑ Ihave aM will mei was CertNcste of Consent 0 xxlfnnsurc for Wmkera Compel- A A
sat as provided for by Sectors 00 3]of the Labor Code, for the al
pturts. a of be
�
workforwhichthispc t sued.'
❑ 1 have and will mdinwn Workers'Compensationdnsutancx! as required by Stiction -
3700 of the labor Cotle,fmihe perfwmeance of the work for which Nit permit I.iomed.'-
/ My Workers Compensation Insumarmcam nd Policy number=:
'Came: policy Na:"
CERTIFICATE OF EXEMPTION FROM WORKERS'''1 •s ;
COMPENSATION INSURANCE-
0Tuxsection need not becompletnd'fthpermit s for one hundred dollars($1 W)
I certify that in be performorceofths work forwhsh thupemm is issued, i shall -.
not employ any person In any manner ro as m bscome.mbjem to the Wlikers' Compen-_
sat on Ldws rf Cehfomia Dme
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should -
become subject m the WorkArs Compensation previsions of be Labm Cosa; you must. ,
forthwith comply with such provisions or this pnmuhelf be dearned000ken.
0 p=x' CONSTRUITIO J LENDING AGENCY
' ;" IM1ertbY affirm that then ecce arucuon lending eBenry fonhe perfoman sof
' r Ne work for which this pcnrut is issued (Sa,309'7, Civ C)
F i�i�••�' Lenders Name-
G(i.yLandbora Address
bzl Icenty Wtlherc h nil we that be WInformations
est t l g t PIY th��y{Iilr a I d ty b antes and tet laws tau B t t o
F7 ,� bultln¢ tmcu , tlM1 I nathoric preventativesof0u city m enter upon be ('
V 0 abov'm t -nd pro, fm "Run mpr,xs
W . - f (We) gree m save ro
indemnify and keep harmless be City of Cupertino against
0 V ;Ilnhilime,jWfronts; command expenses which may in any way accmeagamst said City
'n come
mequemce f d granting of this krun L ' ,
APPLICANTUNDFRSTANDS'ANDWIILCOMPIYWIrHAIi NON -POINT '
SOURCE REGULATIONg r" a I• E,/(/I//(, /If�J/(, Y�.r /%/ 'r
Stionstme of Apphcant/Contmctor GGI_ (� ,
HAZARDOUS MATERIALS DISCLOSURE -
. 4WIl the applic t sure building ccnupant store or handle hazardous materul Re -roofs - ...
✓ s as
defined by the Cupert M 'pal Code Chapin 9.12, and the Health and Safety
-cm sent zss3x ), %` Type of Roof
❑ Ye No
a All roofs shall be inspected prior to an roofing materia] being
Will th eppl cant r future b ildi g a uMnt use equipment or devices wh h
amt lb, r cal weer as defend by the Bay Area Ar Qndlty Management installed.Tf a roof is installed without first=obtaming all inspection
°"""] I a nee to remove'alFnewamaterials�for inspection. Applicant
❑Yes n
1'• 'I have th hes dr'smadearcgmremem under Ehap 695. N eai- understands and will comply with all non, point ,source regulations:
- toms Heal Fety Code, Sanoms 25505 25533 and 25534 I ndersttand that If be
s
building s a ml he rosin, thautis my rexpons bl m tfy the occuparm
of
be P t h'�yyy mom,rbut uwaweofa Cyryry! �y �pn ry _ -
Wll�Ww ' 'T I /Signature of Applicant r Date :.
"wum eamoneedage � Dam
B All roof ebverings to be,Class "B" or better,.1,
OFFICE.
.. r. -