00070047 CITY OF CUPERTINO � PERMITNO.
BUILDING DIVISION PERMIT -C tONTRAC�TOR 6N'FOR+MAIeT,IOO N; -bb Ly
BUILDING ADDRESS: �sI �uz � O/ul / fIC SANITARY NO. APPLICATION SUBIMITTAL DATE
WNER'S NAME: SU Ptd- tbDx 1103
PHONE
-366—6 �j I,zf,,e1 A��ry�////tttlz�/t �^•a �j NIC CONTROLp
•, ARCHITECT/ENGINEER - 9ULDINOi1'EliMll®INF;O
X20 83l 3�y s�33
t LICENSED CONTRACTOR'S DECLARATION . - ..
1 hereby affirm that I am Bansell uMer previsions of Chapter 9(cottuaremg - Job Description
F=�S-� with S«lion]OOD)ofDivieion3 of the Business and professiomCode�r licchsa
myN< inmilfac eHmm. Cy_ LirN 7 - -
S eco U 1Javnatt. _ +
Data Cosused a ori
i.O e . ARCHITECT'S DECLARATIO W
1 undennM mY Phns shall be used u Public ncatls - •
zaaf
i O Licensed Poofesairvl -
vS a
OWNER-BUILDERo. mMe CoAIiON
S2< 1 hereby.(Sere the 1 em exempt from Ne C,mtmno e:Any c law for the
F❑ following tem..(Section 7031.5.euhot. and improve,
&os,Code:Any ciry a county
which it,foes a permit re canwer,e1nr,improve,demolish,or repair enY atmmrt -,.OE'
` prioitoiaissuana.dnnquimsthcepplicamfamchpcmdtmfleuignedmtemnt Sq: Valuation ,
thetheisliaysedpummttothepmi6mn of Ne Cmawc aLimnwUw(Chapler9
(eemmeain"ffiS tinn7OOB)ofDi.isian3oftheBPsil,«awdemfmi=CWc)a APNNumber Occupancy Type
ream M1e u esemq rnvefrom W the bsais fa Ne alleged exemgion.My vioktion of pane y yp
Section]031.3 by anY yspli«nl fa a pertniuubjects the applicant to a civil penairy of `
m mora then five huM«d dollen ISSM).
O Larmrtasof the propert.......Ploya.wire wages re meinolecoepemaGem Required Inspections
will do the work,andtl esuucme,isnot eremitical aoffeued for Ne(Sec.7W.Be..,,
and Profe«lom Code:IM Contmtor's License law Mer not apply to are owner of
proPenY wM1u builds car improv«thenen,and who dors such wart himself or through
his own employers..provided that such impervemente are net intended ce offered for
rade.If,however,the building or lmpmvemem Judd widm ane yese.f compldion,rhe
owner-builder will neve the WoRat of proving Net M did net build or improve for It. /
s
pose of sale.). I
I,
0 u owner of me property, en exclusively convactine wit licensed convrttas to O
construct Ne Mimi(Sec.]l#4,Bu.inms and Portentous,Cede:)The Convectors U.
cenw law dors ret apply to an.weer o(prepe.,who Wilda or imWave,tMeov,and
"comment for such pnjecu with a...escorts)lli'en.ed Nerve nl m the Cons ecnta
U...law.
I am exempt under Sm. ,B A P C foe this..on
nu
Data
WORKER'S COMPENSATION DECLARATION
• 1 hereby affirm under family of perjury Dor of the following declensions
0 1 have and will maintain sCenificate of Consent to self-insure for Workei s Compen.
sation,as provided for by Section 37M of the Labor Code,for the perf.somence time I
work for which Nis permit is i...ed.
0 1 hive and will maintain Warkar's Compensation Insurance,as acquired by Section t - -
37M.fine labor Code,for the peAomuna Doke work(.,which this permit is i.aued. - -
MyWrrYcr mpasaurn lnwrunce tamer and Policy �l.��j�l
Carnot ww�G Policy No.:�lr^t Id—a I
C RTIFl CAS OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE '
(This secdbn need not becompleted aide pereal is for one hundred dollen($1 W)
or lase.)
-
IcertifyMat in me perfonnutce of the work for which this petrrdt is iss nd.I she] -
not employ say person m any ttunar w son,haeme sub*,re the Workers'Compen. .
satioa laws of California.Data -
.Applicant
h, NOTICE TO APPLICANT:If,after making Ms Certificate of Exemption,you should
become subject o the Workce.Compensation provisions of me labor Code,you must
foMwith comply with such provisions or this pe.I,shall W damM mooted.
CONSIRUCIION LENDING AGENCY -
Q (hereby eRrsn mn,then is a constmtlon lending agency for the pertomiv:ce of -
Qn Ne work for which oris permit is i.sued(Sec.309],Civ.C.I
tui Leader.Name -
�[
P". s Address - -
W Icertify mulhave rand thisapplicationNdaWCMet me above lefWlNdon l6
Z corral.I ague to camP1Y wire all city end county oNiwta.sed eros laws minting to
construction, .
U O building construction,and hereby authorizepre
rtnemiv«of Ws city to enter upon me -
above-mentioned property for inspection immoles.
W tui . (We)agree to save,indemnify and keep harmless the City of Cupertino against
C ) C.) liabilities,judgments,costa and expenses which may in any way same against said City
�., W in cotsequeac of rhe grating of Inds pemat.
r 0- APPLICANT BNDF.R3TANDS AND WILL COMPI.Y.WIM ALI.NON-POINT `
SOU RCC:REGULATIONS. . . .
Signature of ACplicanoCnnmtor Data
HAZARDOUS MATERIALS DISCLOSURE
Will ft pplicanmrfo,..building oatipantnmeor handle harsrdeas mantel Re-roofs
as defined by the Calamine Municipal Cede,Chapter 9.12,and he H Wm and Safely
Cade.Section 15532(a)I. � Type of Roof -
0 Ye. ,
e,- Will the applicant orfumacbuilding occupant use equipment ordeviceswhich All-roofs shall be inspected prior to any roofing material being
mit herN
arus air contaminant,u defined B
by me ay Arae Ab Quality Management installed..If a roof fir
is'Installed without st obtaining aftinspection
• "'
❑Y. d
� I agree to remove all new materials for'inspection. Applicant
h wendda h.vdousmaaNsrtq.inmmt,.nd rC un erstands and will comply with all non point.source repulations.•
halter 6.93 of do Cali- PY P D
(oWgd. .d'
a
Safety ian23303,23577 end iS3J4.1 undentmd thu if maNtveaten..t,mmitismymMosibilitylonNifymec,cupehI
robe met prig to iaeuaae ore Cmifican of Occupeay
av• Signature of Applicant
Date
Owns zed.gem Dan .
All roof coverings to be Class"B"or better
OFFICE