03030111 ;'U,,LR_DINO
TY OF CUPERTINO �� -yk� ��T ?.•�y,A� 'ry(�y� '
BUILDING DIVISION PERMIT UNxR�T, �1R YtV
a7' �.
ADDRESS: PERMITNO.
PERMIT Mal A
SANITARY NO. OL N0.
ARCHITECOENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH .
3oD LICENSED CONDUCTOR'S DECLARATION O O O
1 hereby affirm that l am Iicenabd under provlelons of Chapter 9(commencing Job Description
with Section 7000)of Division Sof thc Business and Profession,Cade,and my luensels
^ in full force eM effect
j14 Llamas.. Uc.g DEMO
II.. Dau - Contractor
?QQ ARCHITECTS DECLARATION
•j55�a+tJy 1 un ictmand my plans.hall be used a public records /w i
Licensed Professional /-•ter\
OWNER-BUILDER DECLARATION
,�<E 1 hereby
eqaDm that I am exemptfrom the Contractor', law far the
OO following rnaso..(Section 7 IS,Business and Professions Com:Any city or county
which ruires a permit to marmoset.alter,impmn,demolish,m repair any structurepnormiu4same,ala tee theapplicant for rmiUofile
a signed statement
thathtslicooseapumanto,te povislomofCommuaLccamelAw(Chu9
Sq.Ft. Floor Area
(commcracingwith Section'7000)of n r aribeButmossProfession,Cone)cor
Net h in exempt Moorman and the head for the egad exemption.Any vialty or
Seetheby any appdunt for•pnmltobjecis the applicant m•civit penalty of
not mon than RK hundred dollars(M). 3R'6 NT�FrQQ Occupancy
ccupaney n•
]p
e
❑1,an owner of the property,or my employes with wages As their able compensation,
will do the work and the muctum is not mme ded oraffered for sale(Sm.7011,Business
And Pmfauloru Code:The Commerores Ucen,e Law does not apply to N owner of NO ASSIGNED Rfel)TiBI?EIdgEQll &
property who bu Ilds m improvsa t emon,end who does such wok himsal f or through his
own employees,provided that such Improvements iso net Inanded oroffered for sass.IL
however,the building or Improvement is sold within one year of constriction.Ne own".
builder will have Ne burden of proving that he did not Wild or Improve far purpose of
ulc.).
;ti.
aownerof the propeny.am exclusively contracting with licensed contncmn to"the pmjen(Sec.70".Business and Pro(easimu CedeO The Contractual U.
law dean notapply to an owner of property who Wilds or improves income,red,mracts for such projects with a commcmr(s)licensed pursuant ro the Contracloes Law.
n sae nd"See on PC( th4rDa �R'S COMPENSATION DEC TI Nherby all= nr penalty of pAqury aro of the f mg declanliom:ansnd.01maln n.CertifrnmafConesnuoanlf-WuwforWorkmisCwmpea-,u provided for by Sz lon 3700 of the Labor Code,for the performance of Ne
work for which this permit is Issued.
❑1 hove and will maintain Worker's Compensation Insurance,As required by Seaton
370oof the labor Code,for the perfsmonee of the work for which this permit Is issued.
My Worker,Compensation Insurance caller and Polley number sm:
Carrier: Policy No.:
CERTIFICATE OF MEMPIION FROM WORKERS' '
COMPENSATION INSURANCE
(This smilnn need not h completed if the permit Is for one hundred doltan($100)
or less)
1 coolly that in the performance of Thr work for which this permit is issued.l.hail not ,
employ any person In any manmuo a to become subject to the Workers'C,mpensaton
Lave of California.Date
Applicant .
NOTICE 7O APPLICANT:1f,after making this Certificate of Exemption,you should
become subject an the Wotk"l Compemsadon pwislon of the Lehr Code,you most
.Jz forthwith comply with suchprovisioos M Na permit mail be demand revoked.
O CONSTRUCTION LENDING AGENCY
I hrehy affmn that Nem its construction lending agency for the performance of
the work for which this permit Is Issued(Sec.3097,Civ.C.)
YQ Lend.e.Name
= z Looser's Address
J Q 1 coldly that 1 have read this application and sun that the aW w Information a
mrtttL I egos le comply with all city and county ordinances and tuts laws reining be
7 building construction,and hereby authorize representatives of this city to enter upon the -
NOU anon-mentioned property far Inspection purpesn.
y (We)ague m nn,iedcmnify,and keep harmless the City of Cupertino agntst
to Iiebfltes.judgments,cous and expenses which may In anyway accrue againstsald City
2 In conequma of the granting of this permit.
F7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL N N-PO M' Issued by: Date
SOUR ULA ONS,
C Re-roofs
'gnu o pp) onuantor DAs
ZARDOUS MATERIALS DISCLOSURE Type of Roof
Wllltheep amevfutumbulldlngoceupabnroo"hAMich"urdowmsmrW
as defined by tnc picture Municipal Code.Chapter 9.13,and the Health and Safety -
Code,semte.zss3xa)7 . All roofs shall be inspected prior to any roofing material being installed.
❑los yID Nu
Will the applicant or future building occupant use equipment or dcvlm which If a roof is installed without first obtaining an inspection,I agree to remove
st,hazardous air contaminants a dented by Ne Bay Area Air Quality Management all new materials for inspection.
[]Yes Q.7Y9
I havemAd the honest ousmstedalso iuimmm i underChapter0.95 oftheciffor.
me Health&Safety Codc,SeNms 35505,25533 and 35534.1 undersand lhatifue building
dant tort cumenty haw a tenam,thst it is my respoosihility n'mdf decom 101 the
whkh t be met prior m usumm of a Cenificam of ry.
Signature of Applicant Date
,cone assn, ,m All roof coverings to be Class "B"or better