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00040044 CITY OF CUPERTINO - Bun.n[Nc orvtsto v PERMIT CbNTRAC�T©R I'' FOI RMAxTION: db t��f BUILDING ADDRPSS: ��•`� ae+�.a (� ✓,N— �1�IA�M.�,geG� SANITARY NO. APPLIC^ON SUBMI'�LOTE Z2. 'ZFC 1� 1�P- p. 1�/ rrC Z.!a/ rDVL °'T OW I7� U J 0Ss ��fcl±tel /N//}_��.��l('/�O3/" N❑IC r CONTROLp oN-q1, y 7 ARCHITECl/HNGINEFR [/ / /� lBl LDIN_ftGERMI',IIINI;O 6 .a (94 060.47 I.. v LICENSED CONTRACMIKS DECLARATION 2 O 4� 1 hereby affirm that I am IicenvM under provisions of Chapter 9(commencing Job Description F_C w with Secli.n T000)of Divisiapa of lM1e Buainm ere profeuionv Cade.eM mYlicenu is � G+g P + < H OgvW�iO•ug� - r«I. Y��( 6 9S '7•i8 icam"Cloax SLLy Data Contractor ontr ARCHITECTS DECLARATION 1uMcrtrrod - ' mY piths shall h rood as public,acorea ' gg O Lhemed Professional u7 OWNER xxamPr R DECLARATION t i M 1 beach,.(Sebe that I am caempr stem the Contractttma or,Lilaw far the HM folowngaaon.(Section TBusinesssaid obe Coals:Any city or roomy which rcuw a Permit to contract,altar,improve,deamalah,orrepair wYswewe Sq. F[,Floor Area 1 VaUduaio� • prior la igs iavuence,also aeyuimslhe apPlicenl for such pend mNeealgbed mtemcnt ` r Nat he i,liamed pursuant la Ne provisions ofNC Cpnvaclda License Iiw(Chapter 9 - J Qammsmixgwithhemleo and! f baoion3 me alleged exemption xam tion AnyaudamnOf APN Number ' Cu arc Type that M1s Is exempt therefrom and Ne.peri for Ne subjects the ,he.,I Any,il ugly of 3 p Y Sectipm,703 dorm by any applicant ced milrtm a pemul vubjecu the applicont m..ivil penally of s O rot mart Nan five huMrM dollar y empl. wi Lo 6.ncrardspraprey,ermyempleyeeawithwagenthe'vwuc.myematies, Required Inspections - andll doNewark,Cothe mucturc isnot s LicensaoRemosmarts(Sec.oan owner of and Poofera,who Cods:The vers t Contractors License send w n do s,ac not apply s lf swarf gh propmY who build,pr imadvth Merton,pn who doer wch sank himself or through hi.......oveyee,provided Nu such impr[,,aid a arc eta uncritical a offered fa celee,-Nilldt,will havWilding aimpwvemem[,,aid hedid an, ildori prove far par, nr-huileer will have rhe burden of proving that he did nm build or improve for par, - I - poneof,ela). 1,u t me p of the properly,.Business C a ld Caaenting withCrA ll Tho Crommem ora 1. .mvmua the project(Smpply y04L wneofrole ray who Cade:)Thevem mectm.and came Lew don sal apply je ts owner of property who builds ra lent to m Thereon.cad U..Law.for wcM1 pr.jalg with emnnador(q licensed pamwnlm the Cdna,n.ra U..law. ❑lam ezeminuMec Sec. .B&PCfor this soon Owner Dem ' WORKER'S COMPENSATION DECLARATION I hereby affirm under pcnalry of pujury,one of the following declamations: Ihave and will meinteas Cenificatestl Consent o velf.inwm for Workeb Compen- I O Q caton i ,u provided for by Section 37M of Ne Labor Cods,for Ne performance of the work for permit which Nis is issued. I have and will maintain Workers compematian Insurance.as required by Sacl ort r 37M.(the lsbar Code.for the port....of the work far which this permit is aimed. '+ My Weave oocvsYNp I✓Vmrue prygser and Policy nu art:O V 'ee 7 BTA.. Y Y Policy No,: CERTIFICATE OF EXEMPTION FROM WORKERS'O71L COMPENSATION INSURANCE - - (Thareconsoms, tbecompletedif Nepermilisforomhusd &llm(5100) ' alts,.) I treaty Out in the part...ofthe sank for which thu pemdl is iswM,l shall ' not employ any person in any member so as to became subject to the Worker'Compcn- wlionLau,ofCalifornia.Data - Applicary NOTICE TO APPLICANT:If after making this Candies.of Exemption,You,haute become whim".de Workers Compensation provisions of the Labor Cade,you mus fo t with comply with such Provisions or this permit shell W domed revoked. 0. CONSTRUCTION LENDING AGENCY 0 Q I hereby affirm that there is a construction loading agency for IN Performance of the work for which this pemtil is issued(So,3041.Civ.C.) Lender,Name .. 7 I<Msr,Address - - W Q 1 cenify that 1 have instal this apPlletion and sore that the above info d..i, 0z correct.I spree w comply with all city and county ox imnces and gate laws relating to L) 0 building comuction.and hereby aullwricc repn¢nulivea of this city to enter upon the - W Fabove-IOVia Ale proPeny(in impatian pappus . esju agree m cove,indemnify and keep hay in an the y ac of Cupertino s id City V incommuedg,o fine&,ped expenses isParoich may many way accrue against said city , �. La7 in c.nsequebee of the BmntinB of this permit F_ 9L' APPLICANTUND RSTANDSA )WILL COMPLY WITH LLNON.PD. APR 7 2000 _ to SOUR y(', 110 C.7 ror ve Sigwmrtof App c .effort Data AM21S MATERIALS DISCLOSURE V Will the appLcant or fume building occupant store or handle hssadom material, Re-roofs 1 as defined by the Cupertino Municipal Code,Chapter 9.12,aM the Health and Safety Code.Section 25532(aa - Type of Roof ❑Yes ❑No Will the apPlicenl or future Wilding acupwl use equipment or device which which All roofs shall be inspected prior to an'y roofing'material being 40 mil herWoua ab conumimnu as deFlned by the Bay Arca Ah Quality Matagcmanl installed. If a roof is Installed with first obtaining an inspection ""' I a ree to remove all new,materials for inspection. Appli ant ❑Y<e ❑Na - understands an ills with all non point ource r pulations. '1 Mve red IK hazardous materials myuirtmenu"Mer .1 understand of Cali- P P D fame Hmlm&Safety Code,Senimu 25305,25533 and 23736.1 unecrsund 1 if the b a building does plc heveam Pnorlilismyrtspomibilirym oti(y ncupwt of h moil be met prion.usuwn of e nature of Applicant to moor authori age Dau All toofgcoverings to be Class"B"or better OFFICE '