00040009I ,n
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CITY OF CUPERTINO , ,� - ,.
BUILDING DIV tSION ' PERMIT
PERMITNO.
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BUILDING ADDRESS: -
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SANUARY NO.
APPLICATION SUBh TTAL DATE
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OWNER'S NAME:
CONTROL #,
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RCHITECf/ENGINEER I
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" . LICENSED CONTRACTOR'S DECLARATION
- 1 hereby affi that I sum licensed seeder provisions of Chapter 9 (commenimg
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, .Job.Descriotion -'
with Sauon 1000)ofDivolon3ot the Busrnpiand ProfpsropCm, arWmyh«nu isx
.in fu[If orcearW eff
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CHfTECI.S DECLARATION
- I dorso Y s shall be used as Public records
Ucenud Ro(e99ratul r
OWNER -BUILDER
m ContraON
I hereby aRest list [ aexempt fromm due tee.cense Law (m the
following mown. ($anion 1031 5, Busses and Profpvone Cede: Any city or «u ry
Sq. Ft: Floor Area .'•
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Vlllat�gry .
winch requires a permit m caarwe4 alcor, iinpmve, demolish, or rcpav enY atmcLwe
prior to its issuance,alw requires the applicant f« such permil to files signed statement
that he is licensed personal o ted provisions of Ne Contraclooa License Law (Chapter 9
(communal, with with Secden 7").f Divism. 3.fdW B.uessend Professfo.. CDd0m,
is Any
APN Number '
ane
'Occu Type,
Occupancy �sP -
dust be exempt therefrom and the basis for On ,alleged exempvan. violation of .
5«von 10313 by any appliranL fm a pertmt aubjaB Lhe applicant to a civil penaltyof
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DIhent more'five hundred dollars ($500).
l, ae owner of the psopenyormY employae wire wagemtheir gale mmpepstion.
•. ''-.Required Inspections +
will dothe work, and thestmclure is et intended oroHemal for We (Sm. 1014, Business
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and Profession Code: Ile Coniaatre, License Law does rid apply m an owner of
property who builds or improves thereon, and who does such work himself or through
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his own employem. Provided that such improvements are not intended or offered for
sale.If,howeverme building mimprovememis sold withrmayearofc.mPletimishe
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inaeobuilderwill have the burden Df moving thus W did am build orimprove for Pur-
pose of sale.). `. •
1 in owner of the property am exclusively connecting with licensed contractors to
construct the the project (Sec 9044: Business ual Profeuimis Code') The Cantracw s U
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Claw does e I man owner of property Imo builds or Improves theuon and
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tach )tate sal tra[I r(e)lic need pumnntmthe Canlnctoos
who contmZ11
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L'crnu
adu B&P C for this rep n
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JUN 0 5 9001
own«
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BUILDING -
WORKER'S COMPENSATION DECLARATION"
I hereby affirm under penalty ofperjury oe of the following declensions: :'
I have and will maintain s Certificate of conunOo self-imbse for Woker'r Compen
tion, p provided for by Section 3100,of the Labor Code, for the performance 6f the
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work for which this permit is issued.
❑ 1 M1eve and will maintaieWDrtsr's Compenption lneunnce; u r�uen by Sssu
3100 of tar Labor Cod, far the pef(ormance of the work for which this permit is issued.
d.
Policy number a:
My Wokeend rt
Cemiee Policy
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OM W
CERTIFICATE OF N FROM WORKERS' -
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COMPENSATION INSURANCE � ' "
COMPENSATION J
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" (This section necdnal becompletedifthe permits foreachmWsed dollars(S100)
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orlep.l
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- IccrtifY lbet the PertD fthework forwhlchlhis pemul is Issued. Ishall
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IOL employ e y pe 'n any 8910 bcC mC ilrbJ -CCI [o ihC WOrkCrfi Compo-
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slion
' Applicant
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NOTICE TO APPLICANT: If, of,. making this Df Exemption, you abound
visions f
become subject to Worker's Compensation provisions of Labor Cade, you most
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do
forthwith comply with such provisions or Nis permit shell b<deemed invoked
it
` .CONSTRUCTION LENDING AGENCY-
" I hereby affirm that in. isocommuNon lcrWingagency forthe perkmosnee of
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-the work for which this permit is issued (Sec. 3091, Civ. C.)
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Lenders Name
Under's Address
I certify that I have read this application and state that the above information is
correct . l agree to comply with all city aid county ordinances and sou laws relating m
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building construction, and hereby authorise representatives of this tiny to enter upon the
,above-mentioned property for inspection pw,raxx.
(We) xFor m save, indemnify and keep harmless the City of Cupertino against ,
habilitiu,judgreents. cots and expenses which may in any waymernmMainst said City
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in conu9uence of the grarmog of this Permit.
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APPLICANT UNDERSTANDS AND WILL COMPLY.WITH ALL NON:POINT
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SOURCE REGULATIONS.•
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5ignamm oI ApplicantlCminsctm Data
HAZARDOUS MATERIALS DISCLOSURE
Wll Ne applicant or factum build ng«cupent slrneor handle heaallous meteriW
sad lard by the Cupertino Municipal Code, Chapter 9.12. end be Health and Safely
Re -roof$
Carle,Smile.
yea 255320)?Type
of Roof /�'� �-es _vie -$t A,,e- _ ;
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All roofs shall be inspected prior'to any roofing material being,
Will theappllcarm ar future Wilding occupant use eq p ordevicas which
our harardoue air conomirunm p d ed by the Bay A«s Ah Quality Management
installe ' a roof is Installed without first obtaining an inspection
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❑Yes .. .,-.-
eve all' materials for inspection. Applicant
tandarid.wi c ply with all non point source regulations:
the the/h.�dterialsml' ie underChapmr695ofurCWi-
faw'tore
I. th& S styns 25505 25333 aM 255 W 1 uMeman lthat If tedFuld'
does. um�ntth.tdlsmymsponsbilnymnmdyO.occupantY--e&v
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f myI is saneipnor m issuance of a Catifcale of Occucy
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Igna[ureofApplicant
Date
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wrier or militarized agent Dale,.
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. '- All roof coverings to be Class "B" or better
OFFICE