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00050089 /- CITY OF CUPERTINO " " PERMrrrvO. sort mNcotvtstoN PERMIT f R+MiA1 1%T O O a S o'o g zj BUILDING ADDRESS; - 1:MM - E(,.i FA AVE- SD"ICOS - �'O�J' 4 LC p� SANITARY NO. APPLICATION SUBMITTAL DATE JJWNER'S NA ,oj - 'Z L LC N/C CONTROL# lose, �a 9s12G ARCHITECT/BN [NEER / L 1 A'BER94]71`D51; a (� SSID2'3 r LICENSED CONTRACTOR'S DECLARATION' ! , 1 hembYJarm that 1 am licenred mater provisions of Chapter 9(commencmli - Job Desc^ariw^ption t.:Cm with Section]deffecDi 'ion 3'ofthe BusiusewdProfeaeions Cade,and mY license is ,� / � O,,1`�E lvy�IN`C/t/T$ a in full force esM eRec v,s S �C +I ,40+� •yam Wcens a Lia# - J- K. - - wDase Conttwwr N�-k.AI S 1/�1L a.CI$ O / C g O; ARCHITECT'S DELLA o _ p Ste NCf.AJ S'�4l DE ,,t/ 'Qq„/9 e, , `�' I understand in plans shall h used is public records w L Pro O. LicansW Profcssion.l. . •6 m= OWNER-BUILDERDECLARATION '- (= •'1 hereby.Rrm Net 1 un exempt from the ContracmYs License Law for the O following reason,(Seders 7031.5,limners and Pmfcsions CWa Any cityer county m which requires a Permit to construct;4.1,improve,demolish,o(rcpur any on. S Ft.Floor Area r prior to its isw.nce,almnequiestheapplicantforsuch permit to fire s'realeearmr fl• VaIUHIIOn that he is licensed pureuantm the lowiuonsof Ne Contractors License Lear(Chapter 9 O Z•9� ' S '©00 - (commencing with Section 7000).f Division 3 ofmc Business and Profession.Codnor - a that he is aempl.therefrom and the basis for the alleged exemption.Any violation of APN Number _ Occupancy;Ty)e. Section 7031.3 by eny.ppticent fora permit subjects the applicant to a civil penalty of - am comm then five huatrcA Od.H.($500). ❑ ham.wm4tarthepr.pertr.wmremptoyecawithwage:asrbaira.lecnmpanretim,. Required Inspections " will dothe work,and Ne structure is emintended oroRe4d fmw.(Sec.9044,Re . and Prof eximis Calc:The Congsn,apply to an atractor's License Law Janmer of + property who builds or improves thereon,and who does such work himself or through _ 'his own employees,Provided that such impro armnm e4 not intended or offered for adeAf,however,d4 hilding or impowi mens is sold wi i in one yar.f comple0an,the ' owner-hiller will have the burden of proving that he did not build or improve for pury -' pose of anle.). `+ r „ •❑1,as awntt of Ne properly,em exclusively convecting with licensed aontremors to rease a Nees not (Sao o me Business end Professions Cod<:)The Convector's and nae Law docs not applytots owner of propercr who sed .r tmptuva thermal,sod who se Law. inch pegece wtNecontn<mds)lihnsed puriuent to the Contractors - Licen ' ❑,lam exempt under Sm. .� ,B @PCfor Nrs 4awn � • Owns Dem WORKERS COMPENSATION DECLARATION "V 1 hereby affirm under penalty of perjury one of the following declamtiom + 0 - - Iheve pnd provided far eCem37M of On,Labor Cod,(ire for WorkersCompem .. - s .tion,r provided Pe mi Section 3]00 of Ne Labor Cade,for the pedwmance of the _ cors have l ill permit is isaued. " - Ihave Labor)Wlfon Wperfor Came ofth wImue whince,ch asmq Per by Section 3 of Ne Labor Code,far the performance ofthe yfor which Nis permit is iasuW. ' My Works �nsation lm ranee ttwd Policy y�bpy C sonat C Fbwe�i Po cy N.,:(6*=i 6Cj1�4 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE A (This section Medrnd becompleted ifthc pemmit is foronehunthcd dollars(5100) ' w less.)" .. I certify that in the perfoimence of the work for wha is the parnd t is issued,I shall not employ any Nixon in any menmr w as to become subject to the Workers Compim. ' smion Laws of California.Data NOTICE TO APPLICANT:If,Net making this Certificate of Exemption,you should _ .. become subject to the Worker's Compensation provisions of the lobar Code,you must forthwith comply with soch pmviskns m this permit shall h darned invoked. , Q CONSTRUCTION LENDING AGENCY I hereby affirm door there is a concoction lending agency for the performance of New rk fo hick Nim pemm t' issued(Sa J09],Civ.C.) - a, Iced t' Name s . Lcndef Address - W 0' i cattily that I have mad this application araicam and see that the above cos rehifion to - i LL correct. agree c comply wash til city end county ordinances maxima laws 41st n the - - V 0 h[Iding-hundi..I un.sod hereby wthon urposes. etives o(dusc tymen4r upon Ne " aboJb We)road propene for demnif an Iteep he : - 0;ai F '.ju agree to cove,indemnify end h«p M1 y in m tat City of,mains,s against a ;w hadbilinconomponce of thecostsand expenses which may in any way nccmeagaion said City' _ �., [i] in con. 9menbe of the grwhn6.f this permit ' F Ca APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT a/��rp Qg-/ SOURCE REGULATIONS, (Ij 50[ "I Signature of APplicwt/Cont4ctw Data HAPARDOUS MATERIALS DISCLOSURE ^ Will Ne applicant or future Wilding occupant store orhandle haimdouc material Re-roofs - - as dafined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety �r , Code,Section 25532m)? - Type of Roof El Yea Will therppli.antoffmu�Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being emit Is dome av conwninanu as defined by the Bay Arca Air Qmdry Managemem installed. If a roof is Installed without first obtaining an inspection isvictT ❑Yee XNo I agree to remove all new materials for inspection: Applicant I have reed the bound.,me4dala - understands andmill comply with all non'.point source regulations. r5. r533 a 255M.Irudime5afth<Cau P Y P ., Name Health is,Safety Cade,Sec4on 505 25313 end 255)4 1 unMsend Net if the building does nine dy Plave •te Nat us yrt ponaibility to notify the wcupwt of the re,ircn ma {n�laat f rot pnw t urman e f a Cutific 0��cy •• , 55 Signature of Applicant Date Owner or tied zed en Date , .j i - `All roof coverings to be Class"B"or better' :,; OFFICE .