00040050 CITY OF CUPERTINOR PERMITNO.
BUILDING DIVISION PERMIT" a'C®NTRACTO+ R I FOO RtMATI +O*N: U 0 b u bb SD
BUILDING ADDRESS:- -1
I �est,�t✓t{, + SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NA'E: K y D(05
NIC CONTROLp
PHONE:
_ q�c r�sf/�R s br. y�Is
ARCHITECDENGINEER' ♦ p({25�3- 8332 r ::iP'F II I?DIN(3�PGRAfIT INFO
U
O LICENSED CONTRACTOR'S DECLARATION
Z rm that +
I hereby aEI am licensed under provisions of Chapter 9(,rommencing Job Deseri ption
F_t_w wiNSaeonT00(1ofDivisionJ ofNeBusiness and Rofeniom Calc,and my homes is '. TT
,Syfj in full tome ad infect .S O Sfx , a Q l-eom, )4 bD Hb--7 (T
CC ymj UQarJ I.ILtNC 99_ LiC.N fJ ��t-Un W '�P
f/t
Dale a Convector
t u O a ARCHITECTS DECLARATIOt - - /(/ YLIQ.�CY IrOd'YI(S '✓�S LT '
I undermaM my plam shall be used as public records CVl
p 0 Licensed Professional - a
OWNER-BUILDER DECLARATION
1 beseby RE.that 1 me exempt from Ne CmaracmM1 License Law for the
ofollowing reason.(Semon 7031.5,Business and Professions Cade:Any city or county
u. wMch rcqulnxapermit tummwct,alta,improve.dusediM,mrspauatyawnurc SqFtFloor Area Valuation '
price to its issuance.also reqmdt requires the applicant fre such peto Me.signad sm . .eresen •
Nat he is lieemeii Wnuamw Ne provisions of Ne Connmtda WcmxlAwfCTaga9 SoO ,
(eammnmixemimsenlontandoneiaiamt3afNnegenexemteon.Any,nacde)m APNNuri er - Occupancy Type
'
Ihm le is exempt Nat from and dv buffs for Ne alleged exemption.Any violation of �1 q p y yp
Sadao then
L5 by hundred R for•1)(1). subjects Ne appliunno a civil peaWry of pL—^(l �O 6 SFC
era mom Nan Rvc hundred dollen(empl.
L.dmvm,ax on,of Neptape tm is employees eq fa Ne(Sm.7sole commutation, Required Inspections
will dothn work,ad Ne Z 06mos mal Lacer.Law does.0 a ply to an owned - 11,
and Property
whiob Cade:Tlse Cues the ors Lorena Law does
na apply to an,Enter of
propmy who Wilda or improvea,such
spr who dma such 1intk intended
or or Enough
for
his own however,she
provided Not arch mens I,menu thin not itnendd err offered(w .
owole. -I power will h Wilding hebndere ofrmemiuoW within tWild or cdcremplet
per.ow.-Wilder will have dv burden of proving that he did net Wild m itnptavc fa pv.
pee of aaleJ.
1,as t she of,t Sm 70,am exclusively confessiong with licensed wnuscron to '
construct she Prokat apply
Tan,H.owner
ofa ad PY who bns Code:)The Contractors fid t'
cemeLaw
cts for apPyman ishaonductonywW Wdpmiestover thereon, BUSINESS
who contracts such projmu with acovtrutw(s)IiccnsM punwnt to Ne Convactml '
Licensel.er. -
❑I em exempt under Sm. .B&P C forNis reason
Dwmr ' - Date LICENSE..
WORKER'S COMPENSATION DECLARATION.
s� 1 hrmbY ad
arm uerpenWY of perjury ore of Nwin
e following dmlansiau: � '
QlWve end willmanuioaCmincate of ComenuoselLivmrefro Workds Compere -
cation,as provided Re by Section 3700 of the Labor Cade,for she perfomume of the
work for
have
which this permit i9 issued. 'E ®
❑1 have ed will...We i Wsued. Compensation Immthve,es re9uited M1Y Smtion
J'/00of the Letter Cade,fee the performance of Nr work for reddish his permit is iswd. + /
My Wmkcr's Compensation Insurance carrier and Policy number -
Camee Policy No,:
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATIONINSURANCE O
(This sxtinn need not W cmnPleted ifdu permit is forom founded dalan($100)
or less.) -
'-I mollify Na in the perforrn ,.fNe work for which this permit is issued,Ishdl ,
era employ my
F N avY mmnm5so a�ohecome tiubjea to the Workers,Cooper-
on
Laws of f s.D H (1 6l9 '
Applicant !-.��///Llh ,NOTICE TO o doe Worion"T.ager reeking this visa n s o th Emmptlod you shouldbecom
fordo.ti sea trop to Ne Wmtefs Compensation provisions ofdm IaWr Cde,You most
(oMwiN comply with resp Provisims or Nis permit stall W dared rcvokd.
I.
CON.TRUCI'ION LENDING AGENCY
0 C) Ihereby aErm taucon
t there i9 a sumccon lending agency AGENCY,
performance of s,
=
the work for which this permit is issued(Sm.3097,Civ.C.) I
Ltnder'eam
NeLcAddre.
!
Liz A I mouty Nth I have mad Nis applvation ad state that the above informed"is
6+ mrraet.I agree ne comply with W mdimW city and money nces cute laws miming in '4O
.7 z building constriction.and hereby authorize reprreentetivea of this city to enter upon the
V 0 above-mentioned pmestry for inspersion purposes.
fs
f (We)agree to five,indemnify and keep hermless the City of Cupertino agairut
I
0 W tocoiximi.e g of forcatsed expenses thusperom, may in my way mccmt against said City
W inPPLICANT of Egruntingof Nispermit. - -
p+ APPLICANT UNDERSTANDS AND W'lL1.COMPLY WITH ALL.NONW>INT
� SOURCE REGULATIONS.
� '
Sig..of Appimmuc.."mor - Date
HAZARDOUS MATERIALS DISCLOSURE
Will 0se applicant or future Wilding occupant tore orhmdle hazardous materia Re-roofs
as defined by the Cupertino Mu icipeI Coe,Chapter 9.12,uta the Heeltti and Safety
Cock,Smarr 25532(.)1 Type of Roof '
❑Yes No '
Will the applicant or future Wilding occupant use equipmem or drvices which All roofs shall be inspected prior to any,roofing material being
emith...Wous air Lonumidefined by the Bay Am Air Quality Matagcmem installed. If a roof is'mstalled without first obtaming an inspection
" ' W(/ I a ree to remove all new materials for inspection. Applicant
❑Yes g
I have red the hazardme mztaWs nquirenrnuude,Chapter 6.95 of Nn Cali- Understands and will comply.with all non point source regulations. .
rattier Health&Safety Code,Sections 25505,25533 and 25530.1 understand Out if the
holding mcutsentlYha m t,Nail ismY mpomibility ronotify Ne nccupmt '
of Ne ma whi_chp�y� 'ny�nyP�to issue.of.cerd cafe of ecu -
do; � OO Signature of Applicant - Date '
Owns au zed agem, Date .
',ATI roof coverings to be Class"B"or better,
OFFICE