00050050 CITY OF CUPERTINO PERMIT NO,
y
BUILDING DIVISION PERMIT
BUILDING ADDRESS:. q� J
SANITARY NO. APPL0TIMITTAL DATE
III O ERBNAME: - •� \ � �.�� -s
N �. CONTROLk
674,;z Gol"r vel%- LLA c!�Oe) ElL
"
ARCHITECT/F,NCINEER
LICENSED CONTRACTORS DECLARATION
thereh by eMm cast l sin licensed mover provisions of amber 9(,mart, - , JobDescription - 1
¢yi., with Section 7000) fDinsion3ofshe BusinessandPmfessiou Code red my license is y>� r�al� I �••t�� ��� •) ♦ /� eN1•'a
Lz¢d¢ mfull force and
C R U Lienee I t YLV'ib'
w 3 LL vFi Dem Convector
F pa O¢ ARCHITECTS DECLARA N
z G 1 undemtv,d my plans shell be used u Public mcmda _ ss
K laCCn6ed ProfCa6lMel -
p t4 , OWNER BUILDER DECLARATION
< I hereby affm nh t I ,a nemap,from Ne Cmaremin's License Law for the -
.0 fa"w"gr— (Sct 70315 But..,and Professors.Cade Any city or manly
fagwatch mree e t t truct alar, mprove demolish wcmic
w °" theuch .stimuYt Sq.Ft.Floor Area Valuation
pdortoslicenanpmd nttoratchrepmvisi Bcantforsmautlersoes Lir aUw(Ctnmc9 -
(v....censndS.re noN)of Divisim3of eBuainus Isw(Chaptem
(commencing with Secvon l000)of Division3of she Business and Profeuions Cade)m
Nat M1e is uempt Nererram end Ne buffs fm Ne alleged exemPtian.AnY violation of /%IJJ �, Number F rnType
e
Section 7031.5 by by.,pant foe permit subjects the applicant to a civil peulty of '
pt am than rive hundred dollane(SSW).
Las owver of Ne property,or my ernployuv with wegesutheh ale compenutloe, �,Required Inspections' -
will dothe work.and theavucmre main immalsd moffemd for We(Set 70,14,Rusinees -and Pmfeuirm Cade:.The Contractor'License Law does net apply to an owner of
property who builds or improves domem,and who does such wodc Idmeelf or davugh - -
his own employee,,provided Nat such improvemem,are,not intended or off4md for
+•`.
side.If,however the building or improvement is sold within one yeuofcompledon,the
owner-Wilder will have the burden of proving Nat he did not build or improve for Pur- -
poor of sale.).
y
1.as..of the property am exclusively connecting with licensed contractors to n
crotid Ne project Sm.7W,Business end Profei,ions CWeO The Commoner Li- -
cense Law drat not apply w an.wncr of pmpeny who Wilds or Improves thereon,and 7 . 1 !'
who converts for such projecu wish aconnrictor(s)licensed purawnt in are Contradot'e
License Law.
❑I am exempt under sm.' .B@P C forNis neuro '-
Owner DaceWORy C. '
h I hereby affirm under penalty of perjury onePENSATION of the fol�lowlOng declarations -y, ■ 1 N A L`E D
Have and will mainin.Ce flcet,aC.uell.mlf-insumfm Work sCompen- -,
cation,as provided for by Section 3000 of the Labor Cde;for the palomunce of the UN O 4 2001
work for Ni
which s pemJ
it is issued. -
I have and will maintain Worl Compensation Insurance,u required by Swim
^ 1'
K0ofthe LeWr Code for the performance ofthe work for which Permit lei oro.
My nWarke n n ehrn n4hvn and
nes lies BUILDING
CERTIFICA OF EXE PTION FROM WORKERS' "�L
" COMPENSATION INSURANCE - -
CNissecamnom not WcmnPlevdifthe pemdtis fame hundred ddlars(SI(Iot
or leas.) . I •11 .. t _ '
I ccnify Fiat in the performanceof Nework forwhich this pemus is issued,l shall
not employ any petam in any manner ao as an become subject m the Worl,aW Compen-
sationtswsofCaifamb,Dm,
a Afflicant `, e
NOTICE TO APPLICANT:If,after making shat Ceeificaa of Exemption,you should -
t become subject to the Workers Compensation provisions of the Labor Code,you must'
forthwith comply with such proviaiom ter this pctmit shell be domed revoked.
CONSTRUCTION LENDING AGENCY ' '' u
0 - IhembYalfumther, isa'conurvetion lending agency forthe peRmmanu of r
the work fm which this permit is issued(Sec,3W7,Civ,C.) t `
Fy Lendsle Name
a 1<ndelI Address rt ..
5 �
W ^0 1 unify that I have reed this y and application,end ave that above mimmation is -
'S <rtren.I agree to casup with all city and county ordirunces and erne laws relating to .. _
'.7 z building construction,and hereby samoriu represenativea colds city in enter upon the
V 0 above-metnioned onin Furinspectionpurposes +, I . ' - - -
W F., ,(We)a,ru m nal fy and keep harmless the City of Cupertino against '
C'V les itiea,judgmepts,afu=til expeame which may in anyway accrue against said City
a nsect a ia, it.,of Ws peran.
4 AI . ANT " NDSAND WILLCOMPIAWITII ALI.NON-POINT , • ,
V z S( 'RE
r
sightabuffedf
,HAZARDOUS MATERIALS DISCLOSURE'
Will the applicant or future Wildog occupant storomminu le haandous mmeriel Re-roofs .�
as defined by the Cupemna Municipal Coda,Chapter 912,said the Health rad Safety 1
Code,Sinton 25532(9). - - .. - Type of Roof'
❑Yes �Isa i^ � � - -, .
Wdi Nc apPl can - All roofs shall'be inspected prior to.an roofing material being
t or furore buildidg ac pant use a,,,runt r devices which Cyy
arthnardoua.1,
r contemners a defined by the Bay Area Ar Quality Managemem ' installed.,If a roof is installed without first obtaining an inspection
I agree to remove all new materials.for inspection, Applicant
❑Yes 8�h d
ave read the ha materials un erstands.and'will coinply,wlth all non point'source regulations.
requiremena mon,Chapter 6.95 of de Cali- ,a a'
Tanis &'Safer C .ns 505,25533.4 7.5534.1 undmsmnd t t if the
buildio noesy ant,Nat it is myresponsibility to notify the occupmt ,t
of Ne taw ' or.iuuance d.Cvclu veof cupanc - . .
Signature of Applicant Date
, Owner re onzW
aging Dace ,., •. r a.
` - All roof coverings io be Class"B"or better
,
. 'OFFICE
- - - - at —