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00050140CIrY OF CUPERTINO " 'SLILDING DMSION PERMIT PERMUTING. '0005 UUI40; IITARYNO; APP TION SUBMIT ' OW(N R' NAP,,}E:• l 1�ln\7%g'W /��J'-0� �q ^. NIC 'CONTROLp , El e, �'^' I6?12,�� CHIT TIENGINEER LICENSED CONTRACTOR'S DECLARATION: • 1 . ` S = I hercbY :Kron Na 1 am licensed uMer prhvisimra of Clupua 9 (commnrcing ' , Job Description N rot wish Smtim7")ofDivision3ofNe Businw and ProfmsiomCd mylicesueis in fullforce emJpffycl a7 ©` ���•. - ,,,' /' n.�' - .,•S/ ' • ' gg isz i llcenae Clem Lic. ti . 2r ,• sP / ✓� 3 h Detc, Contractor - ARC FS DBCL N v'1 u H O < ys51g5pybIii,mw r �eaei ane 1 l i °o �TRn o OWNER -BUILDER DECLARATION I hereby affirm that I em exempt from the Contractors License Law dor the I O ,follomng reason (Section 7031 5, Burmese and Professions Codex Any city or county Sq: Ft. Floor Area Valuation •( urrl which requhes a Permit to consumer, eller. improve, demolish, m repaG any aumcurc ' pmeto its Issuance, alae leQalree the applicant for such Issued to rile a signed statement .that he is licensed punorant1. Neproviami none Contractors License Law (Chapter 9 , d _ `• (commencing with Section Tom) of Division 3 of the Business and Profession Code) or —y APN Numb Occupancy 'OT Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of it er y ype Section 9031.5 by any applicant for a permit subjects the applicant to a civil penalty of •' -"" .J - m more Nen five hurarcd dollars (SSm). '� i.U17eCl 1nspecbODS n ❑Lax owver o(tiw piopeny, or my employee with wages as sh:u eolc compnuation, will do Ne work, and the structure is nm inundedorofferel forsae (Sec. 7(d44, Business and Pmfewaions Cade: The Convector's Lt.. Law dean am apply to son owner a property who builds or improves thereon, and who does such work himself or throughf7l own employees, provided that such improvements are not intended m offered forG—sale. .��%his If,however. she building or mrrovemem is sold within one yearofcomPledon, theown.er-Wilder will have Ne burden of provin6 that Ion did nal build m improve for Pur- ' pose of nele.). � • ' ' 1, m owner of Ne Ptri eny am exclusively ommu dug with licensed convectors w cmi]Lt the project (Sec. 7044. Bueinea and Professions Code) rhe Conu mens Li- ti " came law docs tot apply to an owner of loosen, who builds or improves thereon, it i who course is for such projects wish a collusions) licensed puann rsuu Ne Convecto7e Licrnse Law.' ❑ I am.exempt under see. . B B P C for this recon ' Owner De¢_ , - WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of rhe following dedaratioiu: ,. - ' I hrve:nd will meimain a Certificate of Consentto elf-imure for Workers Counties- tow,as provided for by Section 37W of the Labor Code, for the Perfom . M the for which this pemiit is issued •q. _ hive and will maims. Wmica's Compensation hnurantt, as ¢putrid by Section' t, "" ofrhelabor Code, for dreperformaae of Nc wmk for whichthil permisisiesued. my Co.�m,.�"�^'fLmsnasn,In u{ a—m and Poic r5��•Z����% ' .. C�Wak PoIc • a EC RTIPICATE OFE%EMPf10N FROM WORRS' ••_�+' ` -. COMPENSATION INSURANCE'- (This seeinnrnadnce becomplered ifth, pemdt is forone hundred dollars ($100) I century that in the perfotmance ofthe work for which thispemdt is Issued l shall not employ any person in any manner so as to hecome subject to the Workers' Compen- nation Laws of Cali(omm Dae ..Applicant f , . NOTICE 9T) APPLICANT; If, slur making Nin Certificate o(Exemmion, you should `' , hemmc subject to Ne Workds Compensation provieionx of Ne Libor Code, you must •' t " forthwith comply with such provisions m this permit shall W deamed revokel., CONSTRUCTION LENDING AGENCY, O I hereby affirm Out me= is a construction lending agency forth. p:Kmlyv oc of Z the work for which this Pontis is issued (Sec. 3097. Civ. C.) Lenders Name a > n - lander's Address' I cert fy in. I have read this ii liciamn and sure that Ne ado , nfo..men is ' Gla - correct 1 ag=e lot oNwes comply with all city and county ncand use laws ¢tering to �fO building coneumction, end hereby mdomu apasenutnes of this city to enter upon the 'above - r. mentioned property for impecuon pmr,mas e to kap hay Cay OGas Fy f,� (We) agree erve; mdemnrfy and in s she ruCu ales,, igen liabdmes 3udgmenlIn cosuand expense ah mayratany way accneaBanal cid City m consequents of she granting of this- '� APPLI A UND RSTA 'AND ILL COMPLY WITH ILNON.POINT • C.7 SOU EGU HON. / t�, -�• �i •l ^ v r i tare of Applivmulc n ton ; Late ' HAZARDOUS MATERIALS DISCLOS[BtE Re -roofs'" "'� •• a Will the applicant or fuum Wilding occupant no= or handle hazardous material m defirsW by the C.,num Municipal Cade, Chapter 9.12, and the Health and Safety Code, Section 23532(tt)9 _ Type of Roof Y. No Will the applicant or future Wilding occupant use equipment or devices All roofs shall be inspected prior to`any roofing material being .which amt hicaideus arcontaminants .definad by the Bay Area An Queasy Management installed. If a roof is installed -without (first obtaming`an inspection ❑Ys Otho � � , .I agree to remove all new materials:for'inspection. Applicant''. d ' nn erstands and Willcomplywith all non source regulations-.', I heLe reed the hazardous maurWe uiremrnu steer Chapurb.95 of IM Cai' point 'Safety Code, Section 5, 25533 end 25514. I un emtand that if the cu oilhe Rion a' is my responsibili notify she occupant ` •- nt ich t aC sfSignature 4buildin.t of Applicant , " - Date ..., All'roof coverings to be Class'" B" or better 'OFFICE .