00030188 CITY OF CUPERTINO PERMIT No.� �/
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ��� �{ O 8-�tX
BUILDIN�G+ADDRO.... ✓ D
4,0 oft'VQ SANITARYNO. APPLICATIONSUBMITTALDATE
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RCHITEECf GINEER WELDING PERMIT INFO
F
LICENSED
E TOI SpDECLAAION
a N o I hertb dfrmuroFud .
Chapter 9(comitteocing Job Description
with Seem.7MO) I'Divoitual 3 of the Beat...and Prefoli.Code.and myliccner is '
ce
in full force and t.` 7—
ie
F LLO S nuplain shall
ARCNIluse DECLARATION
� 1 undend my plaal h used a public records
rL i C O Gcesed Rofewow
vyS �` OWNER-BUB.DE oDECLARATION
C < I hereby etm Nm
Rat I eci mpt f m the Contractors License Lew for the
C,
following myon.(Section 7031.5,Rueiau W Pe,fe niom Cnde:Any city in county
which require a pewit to ioewck Ater,improve,demolish'mreper tiny"Name Sq. FL Floor Area Valuation
Prins w its issuance,also requite,du applicam for such permit to file a signed structustructure,tcent
Nae he is licensed punuant to No provisions of Ne Contractors License Law(Chapter9
(co councing with Section 7")of Division 3 ofthe Business and Professions Code)in
be,he is swath therefrom and the heads for n alleged cwmpoon.My violuion a APN Number Occupancy Type
Section 7031.5 by any applicant fw a p un d ,min to the applicant to a civil penilty 9f 3 -.eco -Q t 0
mo
ren or Nan f are Wndmd dollen(5300).
❑ I,u owner of Ne property,or my employees with wages u N ir,ole comp nudon, Required Inspections
will do Ne work and the etmcureis ria?mended aohcrolfor We(Sa.70/#,Wusuteta
and Profession Code:The ContucNrs License law docs ON apply N be owner a
Property who builds in impmve thereon,and who does such work hihmelf or though
his own employee,provided tw such mango amu an nm intended or chem,,for
Wu if,however,the building or improo men,is sold within oa yearofcomplWm,site
owner-Wilder will have the When of paving Net be did nm build or improve for Pur �1gigf1)
pew of tele.). �i�' e l m
t]1.u owner of the property,am excluelwly comot ung with licinion correcan m
anis,the project(Sec.7141,Buunw and profeWooa Cade:)The Coamselaa V.
cense law coca wt apply to vi owner of property wec Wilds m er,.do thertov.ted
License tvcufor such aojecta with.conuacmr(s)licensed pursuantro Ne Conuactora
Licence caw. rrrJJJ �,��^v� I' '
I <umptunderSec. .BAP[fof this
O reason La
Ownerer M Deto ecu
WORKER'S COMPENSATION DE IN
1 hereby odfur undereum 3 of.fft owe of the following erfmon cru:
❑I laveand will muntun.CenitimeofCciomin self.i.me brworkds[omPCa
uuon,a provided fm by Satinn 3700 of Ne 4Wr Code,for the performanceof the
wort fm which Nis permit is issued.
ha s W will matnub Winters once Dole,s w rk for whi h his peril by Section
REG
700o rthe W Wr Cab,for In performance dwork for which this permit is issued.
My Worker's Compenuttnn Insurance curia and Policy number art:
Carries PION No:
CERTIFICATE OF COMPENSATION
ON FROM WORKERS'
COMPENSATION INSURANCE 6�
(This wctinn reed out lucornpterdifthc permit isfmone hundred dollen(5100) 0
oil s.) 0
I certify Nate,the performano.....wink Por which'to the w is issued,I shill
not empty any pe o Demonner m as N became,ubjetY N Oso Warken'Compen-
uuonLew.
ofe ata Deal
Applicant—
NOTICE TO APPWCA :Ir,aha melting Nis[en ni of Esemptim,you should
become subject to it Worker's Coons Or t is pmvt sing of Ne Labor Code.you moat
foMwiN comply with such Provisions or this permit shall W darned revoked.
CONSTRUCTION LENDING AGENCY
0 l hereby aim Chet there is a construction lending agency forthe performance of '
z the work for which this permit is issued(Sic.3097,Ci¢C.) '
Undies Name
a Lendera Address
0 I cenify that 1 hive read Nis applintion and ewn that Ne shove infomudon is
correct.)agree to comply with all city and county orduuiues shod state laws seWing to
building conarueion,end herehy authorize rtMunwiva of this city b enter upon rhe
U O ebove�mentiowd property fm inapectirn purpows.
trW P (We)agree ro save,indemnify cad kap hermlus ile City of Cupenino against
C U Babtliuce,judgments.emu anliopeme which may in any way acme agh.tend City
>. ts7 in cm cc;u..of Ne gromung of Na permit.
F APPLICAN r UNDERSTANDS AND WH 1,COMPLY WITH ALL NON.M3lN
V z SDURCI;REC+Ii;'IJ(fiCl. /J
9gnazurt ufAppbce Contncmr Ota¢
RDOUS MATERIALS DISCLOSURE
Will Ne applicant error=Wilding occupentnmre or handle haraNeus mantel Re-roofs
u diOneA by the Cuparmo Municipal Coil,Chapter 9.12,and the HWd and Sdety
Code,section 2353207 Type of Roof
C]Yes LjN
Will the applicant or fumm Wilding occupant use equipment of devices which All roofs shall be inspected prior to any roofing material being
emit hwerdeus air contwninem,es defncid by the Bay Arc.Air Qudiry Management installed. If a roof is installed without first obtaining an inspection
District?
❑Yea 3 ! I agree to remove all new materials for inspection. Applicant
INon read thehaawdw,materials regr;comer-ondir[„.prr6.95ofNeGi. understands and will omply with all non point source regulations.
fads Health Ar Safety Cade,Sections 25505,25533 and 2553x.I understand that if the
WilNngdoa only hawser r,Nu it is mY rtaponsibilirywnwifJJ Ne occupant QU
of Ne in menu wl ch moat wt.6 i.suaae.f.Cenifce oylx ykn .
Ihv ,mautho,2agent / D. Signature o pplicant Date
All roof coverings to be Class eB"or better
OFFICE