00040036S
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CITY,OF CUPERTINO ; -'
'. BUILDING DIVISION - `PERMIT.
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CONTRACTOR 1d`4L'Q.g�,iT.6�1-101N
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BUILDING ADDRESS:'
SANITARY NO.-..
APPLICATION SUBMITTAL DATE
ARCHITBCC/ENGINCLR
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LICENSED CONTRACTORS DECLARATION"
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I hereby affirm Nat 1 am licensed under Provisions of Chapter 9 No"iscing
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with5 t 7i100)ofDivision3ofthe Bus and Profession Coq mylice
inN11P entl effect.
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.4ce xc Class 4c.N
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ARCHCIECTSDECLARATION -
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! understand my plans shall be used as public records
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f OWNER -BUILDER DECLARATION L
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„• 1 hereby emrm then I am'exempl from toConimmoer License Law farthe
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followin6 res (Section 7031 5 Buss« and Professions Cale A y city or county
when requires a perm t m commum alk, himove, demohsn repair any swenin,
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'Sq. F .Floor Area
Valuation
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prior'. its i'also reasons dseapphc ot formch From, an fle. t'luadinatorman
Ne vision of to ContraContracContractor'sLcen Lew (Chep[ r9
Nath licensed pars amt pro
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(commemm�g wiNSechon 7000)of Divn on3 of Ne Bun«ee 'd Prof onx Codc)oi
'Nat he is therefrom W
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AW Number.//-r�.
Occupancy Type
eser thmans ans far the elleged axe mi Any vNl. inn of
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Semon 903 LS by any ePPbcant fora permit subJata Ne apple tt .evil pe'iulty of
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- • t more Nen five hundred dollars ($5(0) '
F ,:'Required Inspections "
p 1 as Worst of the prmeny or my employees with wages or their- side compensation,
will do the work and the structure is not imcrWed of offered for sale ISz 7W4. Business.
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'end Polar ums Code: The Contractors License law d«e not apply to an vv«r of
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propmY who buddy or thiprovio thereon, and who does such work himself or through
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his own employees proideriNu such improvements are not m tended or offer>d far
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side. If, however, the building or improvement is sldwthin one year ofcornphri n,the
"vl,17rwill have NebuMen of prey BN the did -at bis Id onmprove for par
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of salines
1. es ow of the property sm exclusively cohgacdng with 1 «dsed conics to
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r Ne prole., Rst 7(13 Humes end Prof inim s Cade) The Connector. 4
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carveLew dao nut .,Ply i nor s(PropcnY who buddy or improves Hereon d
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whoeonimctsfors hp jets 'N amnvacmr(s)licenved pursuanim Ne Contactor-
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Licions_ ..a
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❑lam cx in Sa. .BRP for Nis sem
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WORKERS COMP N ATION DECLARATION
thereby M. order perailly of pc j y on. of the following declamichis
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❑7h ve and willrmm�tuneCertificate of Co senUo self insure fm Workers Compen
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sau a. provided fie by Section 3700 of the Labor Code' for the Perf ire«e of the
k for whichNta pemut is issued. -
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❑ 1 hue - and will maintain Worker's Compensation Insurance, 9 .msl by SettionMy
3700 alcor Codef Nepedce fN wliynumbe he. permit ions ed.
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sCompemation Insurance carrimand Policy number aro
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CCemer Policy Na. S
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CERTIFICATE OF EXEMPTION MOM WORKERS'
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• COMPENSATION INSURANCE
(Th'selsim need nos be complmeddNe PermitixToro«huMrW dWlima (5100)
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an less.)
•l tend that in they R ceof the wor oro ich Nmtis issuedIshall
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'not employ any person m any manner so es ro hccome eubjmno N Workers' Compen
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moon Laws of California.Data
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APPlicam - -
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NOTICE TO APPLICANT IL afro making this Certificateof Exempilon, you should
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hecnme'subject o Ne Warkeer Compensation pm ions of the Lab« Cade you most-
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mishw N comply with such provisions or Nis Permit shall be domed evoked
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CONSTRUCTION LENDING AGENCY
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I1—b afhrm th rN re' a snow ti nlending agency fonhepMorman sof
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for which Wpe
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Landers Name }. �'
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Lend r Addresx i,
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-1 certify and 1 have read c i o d tel that the above information is
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cones[ I g to comply with 1 c t d Mitunc and tate laws misting I-
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.build g o hmcbon and he by thou p 1 ofdu tyt entarupa Ne
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above -m .,I ... d propehy f ct p I
(We) agree to save, indemnify and keep harmless the Ciry of Cupen ao aBaimt
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liabilities,judgments, tothindespamice which may inanyway eccmeegidmitsaid City
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inconmque«cofihegrantiv g o permit
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APPLICANT UNDERSTANDS AND WII I. COMPLY WITII ALL NO NON -POINT
$0[IRCC REGULATIONS. '� -.
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Sigrtamrc of Applicp- ,f Data
' 'HAZARDODataUS MATERIALS DISCLOSURE
-roofs ^
Will the applicant orfmum build ng«cup tst reorh illi ardous material
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as deCmed by the Cupertino Municipal Cad CT pts 9.12 suite HIN and Safety
Costs, Section 25532(a)n
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Type of Roof
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Will the applicamo fumrc budding upam use amp t rd regia which
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'All roofs shall be inspecied pnor'fo any roofing material being
installed. If a roof is without first
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mstalled obtaining arfinspeehom ^•'
I a ree:to remove all new'materials,for inspection.. Applicant
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erstands and will comply with all non point source regulations.'
adoaam.kdtlamiremm m d rChap t6.95WfN Gaiun
fofety CodeScnioiii 25505 25533 and 25534 1 made mend Nat f N
namrrenllyh cnanLNat r trey mppo sbi ykn t(y Nfoccup iofmi
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of Applicant Date
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` All:roof coverings to be -Class "B" ,or better
OFFICE "` "