00050023 CITY OF CUPERTINO . ' PERMIT NO.•
,_BUILDINGDIVISION 'PERMIT w/ 0� 00.2'`Z) .
BUILDINGADDRESS:,/�
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SANITARY NO. ON SUBMITTAL DATE
�D/ PA0n NIC CONTROLN.
HONE ' VX /7Lt
.� ARCHITECT/ENGINEER - B114D TP ILMI
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Z O 7 3 LICENSED CONTRACTORS DECLARATION „ `
O z p I hereby aRrm that I licensed under provisions of chapter 9 Rommern ng , ,Job Description'
with Satron 7000)ofDi n3 f Bust saint Rofaeiom Cmde,aM mYlicentt .
m full force and nRect
��rc< �t<aeGla�—�e. �7io EXi/s�frrN�w� AS/�NA/ Ly SN/N/
Q 3 i h Dem ?/lelz/1L•L Conwcwr �� . y/�Y(//45L/s J p_ ����/H�r f/ JH' �Ci/G-'�✓
H OG ARCHITECTS DECI,ARA N
I undue my piensshall beccdas upublic ret
i g o Limiand Professional - " ,' '/��0�1'/J M'FC>IZ I!U $7/j Ll./}-!/G/V Sigi .°
u7 OWNER-BUILDER m CLARATION w^ ��XU w ,�'
gZ 4 1 hereby ePomh that 1 am exempt from the Contractor's Licence Law for the + 'V( 'V
NFO following return (Section 7031.5,Business and pernmaiom Code:Any city or county -
m 3 w which rtyuucs a Permit w construct,alar,improve,demolish,or repwr uni.mwmre
prior to its issue"",also rcrc
gms Npermit e applicant for such peit w file a signed statement Sq,,Ft. Floor Area p'Val�upation
Nrs
at he is licensed puuau
no the provisions of Ne Commutes Lt...Lew(Chapter9 " - •60 '
(commcncingwlNS<cuon7000)of Dlvisbn3of Ne Buvnasmd Piofe ions CMe)w ppN N bar
that he I¢exerni therefrom and the W ii for me alleged exemption.A,violauan of Occupancy Jype.
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of _ r
y w
not more Nan Bve hundred dollars("Oh, -
❑'I;as owner ofm<Pmpeny,or my employees with wages ere their vole compemNan� '. ,Required ln5 C ' ns
will do the work.sndthe immune i-mor imeimed or offered for Mile(S.,7044,Businesses , .
I
Bofned.Code:The Com mi License law does not apply to an owner a '•
properly who builds of improver Vumon,and who does such wart,himself or tluough•, J\ -
his we employers,provided tut such improvements are not intended or offered For' .•J/ f
sate If,lumsever,the building or improvement is sold within one yesrof romplwon,the - -
o builder will have theburden of prov g that h bu❑d not Id or mprove for per ' 3 •.
W. f s ). - , ! " r_ i�
❑1 r f Oa
awmP pertY armuclusivelymentracting with licensed contractors to
omuva di mcimt(Sec 7W4 Busman and Profesoom Code)The Comrectors W
cense Law does nut apply to m owner of property who builds or improves thereon,and -
who convects for such projects with acontracwda)licensed pursuant o the COntmcmer,
License law. - - ^
❑I sum exempt under Sec. ,B&P C forthis lemon'
owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aPorm under penalty of perjury one of the followin6 deduauom: -
. F1 have and will maintaina Certific...fcomenuo self-ini far Worker's Compen. rv,
nation,as provided for by Section 37M of me Laboi Code,(ser the perfomence of the
'E Is,for which this permit in issued.
1 have acid will maintain Worker's Commute Imureme,m required by Section '+
the Labor Code,for the Rmlonmem,of the.,it for which this/permit is issued.
MY WWork
Caylst_'l�iq�l/ran9�ggsDR epCP,g,aY num VU ..r 'l
/'rkY//Ard/(9p
CERTIFICATE OF EXEMPTION FROM
COMPENSATION INSURANCE
This section need not W completed lithe permit is foronehunmed dollars($100)
or less.)
I certify mat in the performance often work for which this penial is based,l shall -
nor employ my person in any manner so as to become subjecno the Workers'Clangs, .
intimi Laws of California.Dam• "
Applicam .a.
NOTICE TO APPLICANT:IL afar making this Certificate of Beemptim,you should
become subject to the Workers Compensation Provision.of Ne Labor Code,you must '• + .
forthwith comply with such provisions a this Permit shall W deemed invoked: •s ,.
CONSTRUCTION LENDING AGENCY t
C) I hereby grim thea them is a construction lending agency for the Performance of .
ti •Re work for which this permit is issued(Sec.3097,Civ,C.) "
Under'.Name l'
Landers Address
fi7. Q I I benify tha I have rand Ric`application and sets met the above information is
G4 correct I agree to comply with all city and county ommuncee and sem laws relating to -
si�
.0 Obov
building comuumon,and hereby authonu representatives of this city to enter upon Re - -
b„ ae-memloned property far inspection purposes, ..
la'Fait (We)agree to ave,indemnify and king harmleir the City of Cupertino against
QUO Iiebiliva,jWgmems,<me and expenua which mr,hany wayamme,seassid City
Pin constraint.of Re ,and.,of this permit.
rn APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT - • - a
.V z SOURCEREGULATI S
S gmmrc OfA VC u to " Dam
HA4 A US MATERIALS DISCLOSURE
Wtimes or fur building occupant storeorliandlehazardousmanurial Re-rOOfs "
m ticCned by the Cupertt o Municipal Cada Chapter 912,and the Health soul safety
CodType;of Roof it. t
- a Sectmn23532(e)T v
E]We I)dNo' • '1
-JI1 •All roofs-s
wise the Ecros or Tamm Wilding eco' hall be inspected' TlOr t0 an r0
PP g pant use<qui mem or devices which roofing material bei.
emit hurandous'air contaminants a defined by the Bay Arca qv Quality Man.gement, installed.;If a roof is Istalled without first obtaining an inspection
Dlsalnl ' �/ - ^
❑Yea �t1hNo } W I agree to}rerriove.all new-materials for inspection: Applicant
•I''I understands and'will comply with all non point'source regulations.
I ha a rad she haardoue materials req 'ramentsunder Cheger 695 of the CJi-
f mu H<alth&'Safety Cade Swiom 25505 25533 and 25534.1 and trod Ru if the -
-building does nacumnty hue amnam.that itid myiesponstbtlirywnotify the cupmt
of the mput hich st pin m issmrce of a Cen rtsgtgrof
Ly/y (/" Signature of A Ilton
owner or authonzed t '--�— g pp )' Date 'o
s, All roof coverings to be Class."B"or better
fOFFICE