00030189 CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING fADDRESS � Q Vv( I (te'S`�+- ✓/1�Of
, 0O O/ ✓
/
JM -, 'T— SANITARY NO. APPLICATION SUBMITTAL DATE
OWN NAMEA/3 0 N/C CONTROL#
PHONE ❑-;'L,57 —
10
CHITECT/ENGINEER / ��,) Z BULDINO PERMIT INFO
�0 0 LIS 2--11 74
„«
Z O H y LICENSED CONTRACTOR'S DECLARATION
I hereby aM.that I me licensed under provisions of CM 9(commend
o z o P� ^a Job Description
F,4'Cj with Section]000)d(Diviswn3ofduBusiness vrd Profeuions Cade,aid mylianse is
� 5 in full forceavd eRe�p �//�s- lX? /�{r�/,•'I,f1
.0 U LicenseCl `1'� Wc.N ' Gt..0—• /fes VUfODU •✓I _`
u y Duk F�''1! I� C.ntmckr
C O 2 ARCHITECT'S DECLARATIO .2-S
s �O'o cv
IundenundmypWsshwlbcuudMPubli<rtcmds t�sGL• �j rQ1"� V
of e z Licensed Professional
0"7 OWNER-BUMDER DECLARATION
k ¢ I hereby affirm Net I am exempt from the Contractors License law for the -'
D following...(Sarson 703 1.5,Business aM Pmfeuiom Code:Any city or county
i which requires.Permit in<umwct,other,improve,demolish,or repair my structure Sq.Ft.Floor Area Valuation
prim to its issuance,wm cultures theapplicant fm m
each pedt he Ne a signedmincer it
Net he is licensed pursuant to the provieions of the Contractors License Law(Chapter 9 9 • (�•
(commcrcm,with Sector.7IX)0).f Division Sof the Basin.,and Professions Codmor APN Number - Oeeu ane T e
Men he is exempt therefrom and Me basis for the alleged exemption.Any violation of p y yp
Section 7031.5 by my.,be.,for a pemduubjats be applicant t...ivil penalty of _ '2 _ O 1 O
pm mom flan five hundred dollars($500).
mL.eosaver.rth<property,mmremploya.withw.geenNevaleeompensatirn. Required Inspections . .
will doth.work,redthe he Contractor's
oinvaded Law
not an
comer,of
and Prof who
ons Code:The es.thereat Liana Law does not apply to lf.war of his
ow-who builds m improves thsuch i aid who does such wort himself ordroughtfor hid own amployees.Proddd Ilam such impmssvemanu thin nm intendedaroCc or .Rend for
owneIr,nowev.r,tl hbuildingsem.f,rocnr is sold within oreyldcrim ers.lim er-
' Me
owner- altla will have Ne burden of proving Gnat he distant build m improve for pair-
❑1,as owner of the property,rumBusiness s and convecting with licensed Contractors
t.
construct
are Lo Ne does
(gut.]an orscofand rty who Wionslds
Cede:) pro es rharean, d
care law dos runt apply e ts awns of property saint builds rs improves Norton.and
License tau for such pojau with acrnwckrp)licensed Pursuant kthe Contractors j
License Law. '
❑lam excmprunder Sec.' ,BkPCfar this
Owner Date
WORKER's COMPENSATION DECLARATION
I hereby aRrm under penalty of p<jury one of the following dedthedrns:
❑Ihavear willma tainaC<nifcatcofConsentmulf-insumforWorterbCompen-
mti.n,aprovided fm by Section 3700 of Ne Labor Calc,for Ne performance of Ne
work far which thio pemut is issued.
1 have and will muinuin Wnrhre Compenmtion Imucmce.u rtquimd by Section - `
7 of the labor Cade.forth. rf.rmantt of rhe wmkfor whim Nis permit is seated: ,
' My Worµ�Compacts ¢and Polic�umbmNSC 1 q/�pa�
Camier:/�'pja Policy
CERTIFICATEOF IINN FROM WORKER
ROMWORKERS'
COMPENSATION
'
INSURANCE -
(This ucti.nnad not becwnpleted ifche pemdris for on.huvActl dollen(31 W)
. m leu.) '
I comity that in Ne perfortnenceoftha work for which thlspemart is iuted,1 shall
nm employ my person in my manner so as to become subject o Ne Workers'Compcn- ,
sation Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after notion,rule Certificate of Emirptime,yen should
Woome subject to Ne Wrilers Compensation.,a of the Labor Code.you..at
furthwithcomply with... provisiansor Nis permit ahotl be dsemd revoked.
CONSTRUCTION LENDING AGENCY
I hereby urflrmNn mart int sWetmction lending agency for the performance of
.zee r•r the work for which Nis parnit is issued(Sec.3097.Co,,C.) _
Lumbers Name
Linclue AM.,
f� Q I certify tum 1 have reed this m1brwi.n and sok thin Ne above imimand on is
Ca carat.I agree to comply with all city and county endlessness red stain laws mlating to
i7• z building construction,aM hereby humanize representatives of rhos city to enter upon Ne
C.) 0 above-mentioned property for mints..purposes.
GL P (We)agree ro save,indemnify man kap harmlus the City of Cupertino against
V ludaliues,judgmanta.cau and expenses which noay in any way iscrom ainatmid City
>a W in consequence of the gmmng of this permit 1. •.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
V z SOURCE
S,nwWc.fA,,HWrtXWmmtor U.HAZARDO7ARDOG$MATERIAL,DISCLOSURE
Will y t e Cupertino
or fumrc Municipal
e.chapter 9.12,
andhatrt o baccoodHealth sea maktlw R O S
u de.Sed io the Coperino Municipal Code.Chapter 9.12,erd the Health and Safety
Code.sadm 25532007 Type of Roof
. ❑ver
Will Me applicant or future building occupant use egaipmen,or devices which All roofs shall be inspected prior to an 'roofing material being
emit Wurdoutabcontemirunuasdefinedby the BeyArt.Air Quality Management installed. If a roof is Installed without first obtaining an inspection
°`tec'?❑Yea 2<' I a fee to remove all new materials for inspection. Applicant -
I have raidthe hamrdous maende ox irtmrnrs under Chapter 6.95 of mfr Cali. un erstands and will comply with all non point source regulations.
forma Health Ar Se sty Cade,Sermons 25505,25533 and 25530.1 understand Net if Ne
building sou nee entry have mmntthat it is my rnponsibility kwiY ^SCuPmt ( / _ .3 rfD
of the ' a hien was .ori prior t.issmae a.Ceninsgte Occu yy' —2'I' V
Y 7 JAG Signature Applicant, V Date
Owner or eta .zed agent r
Date
All roof coverings to be Class`•B"or better
OFFICE