00040087 CITY OF CUPERTINO , ' PERMITNO.
BUILDING DIVISION PERMIT- '°'ON - Rt1 g'T, t0 IiN' IOR+MAaTION: Q r�, to
BUILIDINGAA7�D'DDRRRESS:
y� 1 .Y G►7 �'LP hI� g%/'•'e° SANITARYNO. APPLICAATION SUBMITTAL DATE
00
OW R"NAME,: " ��,140A rt"
N // _' yy� •., ('- NIC CONTROLM
,H N^• 'V C/r jTV a<� //•L. OWN G "
OS
S6 . 6 'e
ARCHI' :CT/F.N NEE - -� QRULUINGTI;LR'M17fL 1,0
°
IR
A n nil I T Mn�G
tedt->Z - LICENSED CONTRACTOR'S DECLARATION
Z=° 1 hereby affirm that I un licensed ower provision.of Chapter 9(ammenciog ! . : 'Job Description ,
Infall
ecforce
and
affect.ivision3oftheBu,incu sad Profwi<mCale,Wmylicemei, `1��„<, ~- D� M157'1 P_C-5 100
0iU E
Llanse Clan Lia N
ugh Deu
Con
tnc _
t t_y O g AARCHITECTSC
DECLARATION -
� lure nand my pt s Jl bets p tic '
IuS OWNER clamp E0.DECLAMTION
1 hereby season.Stat on 1 1. exempt from N<Cessions rs e:Any c law co the .. .,
SG following.m. (archon]rimae Buslmsamp professions Cude:Anycin arcwnry
a m which requires a permit ro cammrcL l improve,dcmohm,m optic any snucnue Sq.t.-F�1or`,Area �a Val- uatign
perheisscensedsm e,Jrorequiseetreappllmnt forthe sarcContractors
Liceseigned(Chapter
- ,aQ/s!r/b 9_0'
that he is licensed punuint to The provi.ionsaf the Connamre Licenm Lew(Chaper9
bommcncing with Sectinn]Iwo)Of Division Sof the B.,i .a and PrnfmJnn.Code). rets anc APN Number type
that he I.examin thnefmm and tire basis for the alleged eumgion.Any vio4tion of !'' P Y YP
Section]031.5 by any applicant for a payout subjects the applicant to a civil penalty Of- !o '
not mom than five hundred dollar(55001.
'p I,zsowna of the propeny,mmy nnployen with wagesas theirwl<canpewtion, ” Required Inspections "
will do the work awdleewaum is nor munaloll oraffertd for We(Sac.]Od<,Busiwu -
and Pmfeadom Cada:The Comncsors License law does not apply to an owner a
property who Wilda or improves thereon sad who does,tach work himself a through _his own employees,provided t od,such improvements are am intended or oRerud for r
We.If.however,the building or improvement 1,sold witldnam yeuafcompletion,the rya
owner-builder will have the Nolan of proving that M did nal build m improve fa par- V
,pro Of We.).
I.u owner of the property.an Business
contracting with Breus,C mina . t0 !!// �
nsuuct the project(Sac.o an owner
o f sad Professions Cade:)The Cmuectors Ll=
cense law choreas apply je ts owner of property who builds or ant to the Corton,er,s
what.. nets for such projects with acontnaorfq licensed pursuant the GOntradWa O
ucmm law. O
❑lam exempt under Sec. RBPCfor this reason - '
Owner Date ti4 ._ - -
WOR COMPENSATION SATION DECI.xRAT10N
I hrreb,sffirm under pmJty of perjury oro of tho following declarations:
]Ihaveaadwillimmulna Cenificauof C...ard ailf-insumfor Worker'.Comprn- -
-lion,as;provided foe by Section 3700 of the Iabor Code,for the performance of the ,. •- v
work for which this permit i,r issued.I -
1 have and will maintain WcAm's Compensation Insurance.as requue4 by Section
37OOof the limbar Cab,fn the performianceofthe work for which this permit I.issued, •,
My Workers CompntaationInronnca cxrnrr and Policy number am:
Cartier. Policy baa: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'. _
COMPENSATION INSUMNCE
(nil firm.eldnat beccandeted ifthe prom,is(Oros hundred dollas(SIM) -or less.)
Iccnify that intheperfomao<Ofthewmkforwhichthlapemnit is iaaadd[shall • - ,
not employ any penon in any manorr eco a ro become subject m Ne Warken'
Applicants
ppliCompere-
Appli aaws o(CJifomiy Dae - '
cant
NOTICE ID APPLICANT:If,after making Nis Certificate o of Ubor o d you should
become subject m the Worker.Coma,or din, provisions of the Lebor Cade,you mast
foMwiN amply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
0 Q - I hereby affirm thu then is a camtmction leading agency far he performance of
Z -the work for which thi
larnees Names s permit is issued(Sec.3097.Civ.CJ
[�
17erdar`a Address
k7 1 unify that 1 have read this application and sate Cut Ne ibove infomtatime is
V O urser^.I agree m mmPly with all city and m
county dini ncea and stats hada relsom .
'n
g communion,and hereby autism,reptes<n a iver of thi,city m ants,upon The
above-mentioned property for inspection purposes. : t,
W t:. (We)agree to...Indemnify and kap lutmles,the City of Cupertino against ,
0 V llabiliti<e,jwgmcu,casts andapemes which may in any way name against laid City
,y W in etsmequcme of the gmndng of this par t.
F+ fir APPLICANT UNDRRSTANDS AND WILL COMPLY WITH ALL NON-IN)INT
V Z SOUIICE REGULATIONS.
Sigmwm.1 ApplicanVContnctm Date- -
H RDOUS MATERWS DISCLOSURE I
Will the applicant orfu.urt building oc.pam more or hawle haWou.mearial Re-roofs
as defined by the Cupertino Municipal Cede.Chapter 9.12,end the Health and Safety • ' '
• Code,section 15532(0? 5�, Type of Roof ,
Will fire applicant uet.0 obuilding occupant usecquipmemor devices which All roofs shall be inspected prior to any roofing material being
emN
it hud ous air conuunirunu as defined by the Bay Area
A40uabty Management installed. If a roof is Installed 'without first obtaining an inspection
❑Y<a I agree to remove all new materials.for inspection. Applicant
�r+o
Ihave road the ha„r(W.m.tionala understands and will comply with all non-point source regulations.
rtquinrmnts wader Cllapur understand
of do Call.
forma Health tit c.m code.Satiom 75505,25533 and 7353<.I uadraatmd the B the .
of Cheng dims nor"whiclY have.¢oast.Net it is my mponsibility ro naifY The omipmt
of the rtyuircmenu which musy�nm prior to issuance of a Cendiceenf q'cupmcy. - - `• - ,
ra N `�- 1'61 tto Signature of Applicant . Date.
Owm,or. oozed tv a0r¢
All roof coverings to be Class`B"or better
OFFICE