00030202 CITY OF CUPERTINO. - PERMITNO.
BUILDING DIVISION PERMIT '. CONTRACTOR INFORMATION:
BUILDING ADDRESS: - - ^ tiANITARY NO. APPLICATION SUBMITTAL DATE
�+ OWNER' NAME:- 71M415kJ rL WC' 'CONBOLa
AL I PHONE: JI/ 56-53oa a,9 oaf.. 75"ZZv
.ARCIIITIiC'I !NGINHH - BULDING I'ERMITINPO
lel,Ai . Assocr s o21 �3SZ P
LICENSED CONTRACTOR'S DECLARATION
3Z_o Ingmhr assns,lba f,mu«n«a nna<r pmviainm nr cn:P�r9fenmme«ire Job Description .,
_v:Cw with Section'11100)of Divuaon3of No Buainneand Dofetion:Com.anti my licensais
s.y�5d•� .in rullforce7�=E effect. - /•'• /�� /�� l /�� /,//f�/� e ���I���}}'
a boa
O etc CLARATIONI trapublic records
uS O U,Id armProfewlaW .
y ^_ OWNER-BUILDER DECLARATION s
1 hembY affirm neat un exempt from she Contractors Liconse law for the
SFC following reason.(Section 7031.5,Business and Pmfeuions Code:Any oily for worry _
a3 •which regwrea.permit m cosuwct,.him.improve,d<raoliah,m repair any awcmrc' Sq. PI. Floor Area.,. Valuation
prior m its i.tumtm.also sequins sheayplicam fmaah peneuuned o file.siganuiremtl -
shut he is licensed rtt thebrovismma the contracmr;Lcen Lew(Chapter 9
(comm g 'thy il. 7000).17 Diion 3 Of the Boadran.Rod professionscndo) n 3'APN Numb r - Oc upancy Type . .
in.,hes mPt therefrom and dm bas's(.,,he alleged exempts Any vibthon of o —D� O�s
Sectio 703 1 5 by any applicant for permit subjects the applicant to civil pendty of ' v
Qa mom Nm five hundred do]].('500). .
I,as.warn arum propcny,or mY employ«e wim wage.as their.conspads.aon, - Required Inspections
will do the work,and the structure is sort intended or offe mm for We(Sm.7044.Business
and Pofa:i.m Code:The Cmuracbrs License law it.one apply to an rwnor of ,
property who builds or improves'hereon,and who does such work himself or thuoagh . . u
his own employees,provided abot such impmnmenu an not intended a offend forWe.if.however,she building or improvement is sold within one yeuofcompledon,the.
' wnel-Wilder will have the Wre ce of proving that he did nos Wild or improve for pa-. -
posorfmle.). -
I,as owner of the property,am exclusively convecting with licensed consumes to '
construct Ne pmjat(Sm.7044,Business and professions Code:)The Conwcmes Li.
nulawdoc'ma. man.woos of 7
pp y property who builds or improve.Nemon,end
whoc.mrsms for such projects wish aco.. .. glicensed pursuamm the Convacaors .,
❑lane exempt under S«. ,p&PCfor Nis raven --
Owns Dace - . . 1 - .'f4;!F..: - .
- WORKERS COMPENSATION DECLARATION
% CounI h 6Y ff m under penalty ofpcqury:me of the follow g de 1 ne ti
❑Inss andwill for
Swoen 377 of the
Labor Code,for
Woknc�e of the 'V
ter-
Ration, r provadhi for mi Swoon 3700 of the Labor Cade,for she per(.rmanh of the
work tea which this perms is issued.
❑I have W ill..law.n Wakcrs Compensation Immanum,as nquisW by Section
3NOofrba scodgfor that oohcw k for which Nis permit is stood.
rwli 1 carom .rod umber en: '
Cam
CERTI lE0 E ON OM WORKERS'; -
COMPENSA NINSURANCIi
(This[Karon not bocanPle ifmo pemdl isfwone hardral dollen(3100)' - . . '
or lees.)
IcenifYN in she pedormencc of thewak forwhich this pearaul is issund,Ishall s
not employ any person in any manner to as to become subject to mit Worker-Comiten-
aaucn Laws of Califom o Dar - - -
Applicant t
hbMCE TO APPLICAM`.If,afar making this Certificate of Exemption.you should
hcwme subject at the Workers Compensation provisions of IN 1,ahor Code,you must I ,
forthwith comply with such provisions ce this parmit shall W deemed mokW.
CONSTRUCoON LENDING AGENCY .-
O Q IhercbY•Rmth'unam is """salon lending agency police'K.—CO of -
Z tithe work for which mu permit is Issued(Sc.3097,Civ.C.)
Lencke,N.
IY 1<nders Adder .
0. 0 i certify than I here with&D city said
cLun and ala.Naso she above laws
Waling
altto
0. contact.I ogre ucicomply. d with JI airy.rad ceunry ntdwncof W sum Jews r upon t to
V O .1tovengcrioned construction.and to;
aumoniurosises.representatives of this city menus upon the
above-me e).,,m ropeny findem indemnify
an pmpowa. ..
0pw l (We)agfeemsave,indemnify endkeep hays anahe City
ruCupertino.gains, -
OV IiLbiliti<yjudgm<nU,ca`u and expense which may in any wry.cweegainn said City
Frv'tb'AV:)' iAn Pp,.,c ueaeUof Ne STANOgSofAorNiDs WILL
COMM I'Y WiTfALhNONdR1N1
SOU :REGGLATION ' r
a Sgnatma of Appl'nnJCom Ito Dea
HAZARDOUS ATERIALS DISCLOSURE
Will Wi m ifiarvreb riding occupant store or handle haisup—material Re'roofS ,- .0
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cods.Section 25532(an s - Type of Roof
❑Vas ',gAb� .. '
Will the applicant Of future Wilding occupant use equipmom or devices which All roofs shall be inspected prior to any roofing material being
coria hawmous airconuminanu a,defimd by de Bay Area Air Quality Management installed
If a roof is installed without first obtaining an inspection .
Country I a ree to remove all new materials for inspection. Applicant
f ❑Y<s �. �,:. agree
I have mad the hanasdous m..dart requiromen4 trader Car tinderst ds and will tom 1 withal] non oint source regulations.
ptKM193 rf dee tali- P y P p
fano Heal &Shfoty Code,SKdom 25505,25533 end 25534.I undenund that if Ne r - "
building snacurrentlyhev ohm it is my ponsibilit,oro naify Ne.ccupms
1, eau wM1ich moor. mer or su us ceofe Ccrtificeae of Qcupancy.
rc I ature of Ap ant .,- Date ..
nit or authors. .genet .. Dale ••
All roof coverings to be Class"B"or better
OFFICE