00040008CITY OF CUPERTINO -
G®N a ME1 ION.
PERMIT NO. "
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APPLICATION
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ARCHITECTMNGINEER
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LICENSED CONTRACTORS DECLARATIONn:.
I hereby affirm that w licensed under p nms of chapter 9 (cotrmewmg
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`Job Description
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with Seclon]0003ofDlvrston 3a( the Beturims m,d Protessidn Cade, admis L«
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ARCHITECTS DELL O
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J understand my Plans shall be used as Public retards
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LicensW professional
OWNER-BUR.DER DECLARATION - t.
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1 he.;, idificere that I am exempt from she Contractors License Law far the
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toll g (ganon ]031 3 Bmrrc d Prof nom Cade A y ty ry
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penin roc alrcr Pr° e d "mi`
wbch IN `
S Ft: Floor Area
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in t .ulna ala rcs Neapplicant f h
poo rcgotpemutwNeamgned emamrnt
rescue, the iment
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Nath to the provumniofof
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(commencingwithSectionbe
(comeisca w,NSedlon]0007of basis or oft heBusmenandProf taoecdomof
t. . Any pausbm of
t M1 r exempt therefrom and the burs for the alleged axe
,AP^NNumber' .
' Occupancy Type
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Section 7031.5 by any applicant for a permit subjects the appy t I.. civil petulty of
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t more tben Ove hurW A dollars (5500)
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, Required Inspections
❑ 1 aaowneroftheprapeny INmyemployemwMwegesuthe' a Iccurnmostion.
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will do Cade sINv
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lesions
and Profusions Code: The Contnereco Liana Lew docs lwt apply to lf owntt of
he Contractor's
oLicenseLawdo apps t anmam r of
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s thereon, and who does nM1 work m through
progeny who build. or vided
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t a peed or
'his own employees, provided Nn such improvements w not intended m phare, forsub.
is m lefaq the
f, hnwevw, pew builthe
ofcouor
id non
mono burden of proving he
1'owmr-Wilder will have the burden of proving that he did not build or improve for par-
Wild improve
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of the progeny, aiB exclusively convecting wish :)
t the project TheM stream is
ow ]Ona, Busowner
and Proroy bo Code:) The Convector's
on
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who and
whosedporimproves dammonContractors
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lirojecn witheeontnemNs7licenad pursuantto the Contractors
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Lima. Law --Hoch
Licence law. - 1 11•
Lima.
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❑ Iw exemptuMerSee. ,B&PC fm thiirwan
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Owner Dale
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WORKER'S COMPENSATTON DECLARATION
1 hand w aRirm ander pendry one of the following dedwtiwu>
and i reperjury
❑ fe WBhera
(.he
on, se
of
,shoo, provided Labcerst r Code,self-ifort
id for byn Section 3]00 of Ne Labor Codc, for the performance of the
Ss ce of the
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wink r ch m issued,
Permit issued.
have a
❑ 1 have end will no en
maintain N'admrs Compensation Insutmce u req rad by Section
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or
3700af the labor Code Lor the Pe rmom of live work for whichths pcormi aim ed.
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MY Woratmn In 5 tt m Policy,
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CERTIPICCOMPE XEIONINSFROM W KERS
COMPENSATION INSURANCE
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' '(Three secrion need nahcomplemdifthe pemdtix forone huMrtd dollen (3100)
or Itis.)
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I coolly that in the pefmmanceofiie work forwhich this pamet is issued, I"I
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not employ my person in my manner so as to become mbjecno the Workers' Common-
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.ration Laws of California. Data
Applicant
. NOTICE TO APPLICANT: If, after making this Cer ificam of Emeriamn, you should
become subject in the Workers Compensation provision of the Labor Code, you ..at
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fonhwiN comply withsuch provisions or this potmWhall be domed revoked
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CONSTRUCTION LENDING AGENCY
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I hereby affirm thin Nem is a construction lending agency for the performance of
the work for which this Permit is issued (Sec 3097. Cie Q
Landers Name -
Landers Acidness - -
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that i have react application and snm that the above information is
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motrcct agree to comply with all city and county ordinances and state laws relating to
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buildin cmetomon and hereby amhonarc
¢ y ores. Ives of Nncrymenwr upon the
aMve mentioned pigmy far indemninspectify lacep es.
"(We) agrees, cove, indemnify keep harmless City
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and the of Cummins
Bebilitiu,judgmems, costs may in any City
City
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way accmeaguno said
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in consequence the granting of Nis permit.
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APPLICANT IINDP.RSTANDg 'D WIILCOMPLY WITH ALL NON -POINT
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Sig t pphcmtl n tin Date
DOUS MATERIALS DISCLOSURE P,-
Re -roofs
Wintheapplan rfutumhildin mw pmtsmrcorhmdlehnvdousmmanal
az defined by the Cin
ina Municipal Code aid 912 ethe Health and Safety
Code, Section 25532(e)
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Type of-Roof,
Elyse
Will the applicant or future building occupant use equipment or devices which
All roofs shall be inspected prior to any roofing inaterial being
doescart°ntarninm��,///taa.deffted by the BayMaeAnQualityManagement
installed. If a roof is installed without first obtaining an'inspeetion
istrmithic
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I agree to remove all new`materials for inspection. Applicant
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Ihave real rhehaarrdouam¢ndas Chapter Ctli-
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understands and"will'com 1 with all. nofi,point source,regpulations.
comply p O
roma Health B Safety Code, Sections 25505, 25333 and 25534.1 understand Nat if the
251533 a . I rad lout
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buildingdocsno rteady eveateum, 't's mY rtspouibiliry in notify Ne occupant
of Nap wbi 1 un ba met t uummeofacm-fi;/ c
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Signature of Applicant Date
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Ow euN e Dam`
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All roof coverings'to be Class "B" or better ,
OFFICE