00040125 CITY OF CUPERTINO PEWIT NO.
BUILDING DIVISION PERMIT CONTRACTOR„'INFORMATION.” • 00 Q 'L4 01 Zs
BUILDING ADDRESS:
O ^,, N SANITARY NO. APPLICATION SUBMT[TAL DATE
W 'S NAM lv lJ 1
III 0"an fK,4
any (I O n NIC CONTROL#
PHON S`6/— Y F-^ a�
ARCHITECT/ENGINEER BULDING PERMIT INFO
�z GS� x /- 0757
w oM
X O h ' LICENSED CONTRACTOR'S DECLARATION
O Z— 1 hereby 0).f tat I em mesea inlet provisions of Chapter 9(commencing - Job Description,
F Cu9 wiNSar.and ) f on3of rhe Busin<u ani Rofeesiom Code,and myliumeis
infull fo and cRccci /
k"e<`I�ya VVVVV�— ��.emr •l.
k
is 7- ARCHITECTS DECLARATION
S 1 ioular and my plans shall housed as public records
ii!y Listened Professional '
u3 OWNER-BUILDER DECLARATION
C X¢ 1 hereby"Rem that I am exempt from the Contractors License Law fer the
Q following reason.(Section 703 1.5,Business and Profession Code:Any city or county
ori which returns a permit to construct.alter,impose.demolish,or repair any structure $ Fj�FI or Area Valuation
poor to its issuance,also mr doe,the applicant for such permit to foe a signed statement
Nat be is licensed purswnuo the pmviaions of Ne Conuacmre License Lew(Chaper9 /wVt,J ys�� '
(commencing with Section]0W)of Division3of the Businew entl Pmfessiona Cotlela
Wt fie is exempt therefrom and the bmis far rhe alleged exemption.Any violation of 9 APN Number . Occupancy Type
Semon 7031.5 by any applicant for a per-ort subjects the applicant o a civil penalty of 3 G, {— 3 y —
net more then five hundred dollars($500).
I,as owner of the propeny,ormy employees with wagesutheir sole compo..mine. Required Inspections „
will dome work,and Nemsucurre is.1 bntendedmoRered female(Sec.7W.Boomer ,
-and flofexsiom Code:The Convaaor's License Law does nor apply to an owner of '
property who builds or impmws thereon and who does such work himself or though
his own employees,provided Our such impovem til,art not intended or offered for
sale.If.howeur,Ne building orimprovemenriuold within ane yemo(completion,Ne t
wum,builder will have One buNen of moving Nat be,did eat build or improve for Pur-
pmeofsale.).
1,as owner of me Property n to
,nexclusively contracting with licenced comosero
s
comnuct the project(Sal.7066,Batteries and Professions Code:)The Contractor,U.
".a taw does not apply to an owner of property who builds or improve,Ihereem,and r
who contracts for such pe jacui win a conbaclor(s)licensed punuNt to Ne Contractors ' -01
ostia also. 3/9
❑lam exempt under Sec. - .BkPCfor this reason /
w r Doe
WORKERS COMPENSATION DECLARATION ,^
1hereby alarmundopemlry teperjuryoneofinefollowingWorl a Co �•J
❑m,sis end will for b in aCeni 37M ofConsen or Coda,foo for Workers ce of the
work(r provided for mi Section 3]00 of Ne Labor Cade,for the Performance of me
work for which suis permit is issued. -
❑I have and will maintain fthe
Workers Compensation Insurance, required by Section
3700of the Labor Coda,
,Por e performance nine work for which
suis Permit uround.
'
' My Wo CCo�m nsetio Insurance curio end Policy num ,eek
Carder. Policy No.: �1l'[ .
Ocyu ,OFC%EMPI'ION FROM WORKERS'
PENSATILf ICp RANGE
(This section nced nal tee completed ifNe pcmdt is foronehuMred dollars(5100)
or les.)
I certify mel in this performance of me work for which suis pemdt is issued,]shot]
not employ any person to any manner exas o�abewnteyytbWorker'Common
asomn Lows of� i
NOTICE TO APP rhe Wor ees Cor making Nis Certificate of m Lmor od you should
=at '
become round to the Workers Compensation provisions[of me Lebo Code,you must
forthwim comply with such provisions or Nis petmir shall ed dcemed rooked.
CONSTRUCTION LENDING AGENCY
p' I hereby afRne that Nem is a comtsuction lending agency for me performance of "
► h the work for which Nis permit is issued(Sec.3097,Civ,C.)
E., Lender,Name _
[� Lenders ores,Ad -
{rot 0 1 certify that 1 have read this application and state Nn the above information is
lY correct.l agree to comply with all city and county ordinances and suite laws relating to "
U 0 building construction,end hereby authorize represemmiver of this city to enter upon to
movememloned popery Sir inspection purposes:
W Ey (We)agree to save,indemnify and keep harrows me City of Cupertino agnimt
�sV Babilifies,judgmcnts,costsand expenses which may in my way accrue agalmt said City
in o
mmm— we of me gromm"of to
permit.
aF.a APPLICANT t DERSTANDS AND WILL COMPLY WITIf ALL NON-POINT '
V � SOURC 5.
Signturt of AplinglaMlIfilivistor Data
HAZARDOUS MATERIALS DISCLOSURE
Willmeepplicaumfuture Wilding occupant store orheadle hazardous materialRe-roofs,
at defined by the Cupertino Municipal Cede,Chapter 9.12,and Ne Health and Safety '
Codes Swian 25532(a)7 TypeOf -
Will Nc applicant or future building eccupmt use equipment or devices which All roofs sha 'nspeeted prior to any roofin a being,
's havrdous au conuueinants as defined by to Bay Arca An Quality Management installed. If aroof I alled without first nig an inspection
I agree to remove all new Mals f spection. Applicant
[]Yet d
I have mad rhe buudous mmenals rcquimments under Chapter 6,95 of Ne Cali- un erstands and will comply w' on point source regulations.
Trioti Hulm @ SO t Cade,S 'ons 25505,M533 and 55536.I understand Nm if this'
building ono ea 7.1,Nat it is in,responsibility to rarity me occupant
of the t poor to issuance of a CMifico fo�PaM.
trJ
1Td • Signature of Ap I' Date .
Own monad agent Dote
All roof coverings to be Class"B"or better
OFFICE
T