00050074 CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0170,�54007 4
BUILDINGADDRPaSS: �f
216 �� 1 p Q Q�� SAN ARYNO. APPLIGTIONSUBMITTALDATE
OWNER'S NAMP.:' �lAl Kt �(.�V b 1,�1/
y �- n `%Cir 4 i(`I-y�y N/C CONTROL#
IONC:
❑
ARCHITECTIFNGINECN
HULUINO PERMITINPp
Gsa- oda'-7316)
6 LICENSED CONTRACFOR•S DECLARATION
zO c� m th
1 hereby aRrat 1 em licensed under provisions of Chapter 9(commeodng Job Description
to wish Salion 7000)of0ivi.ion3of eBusinessrod Profasiom Cede,ed myliana is �Pj�O,� f�' {c ♦ /s/4t�
,u in full force ad cB ems'
Liaore Lia N
3 H Derc rSDE —
C O a ARCNI'IECTS DEC N
S y 1 undenund my plans shall be usctl as Iic pada , (4 ^l
Ca¢
a a O z licensed professional - a-
uvS'4_y OWNER-BUILDER DECIARATION
C < - 1 hereby aRmn that 1 Am emeopr from the Contractor's License Law for she
T O following reason.(Section 7031.5,Busiass and Professioas Code:My city or county
ou _ which na tires.permit to construct,alter,impmve.&.Jim,to repair my.vunwe Sq. Ft. Valuation
priorteitsi...A.ce,also require.the applicant f.,,.h permit Elea siu
g edaereml
that he is licensed possum,to On,provision..(the C...l.ea License Lava(Claper 9 Q `Q� OD
(ommon.ing wire Section TMP)of Division 3 of the Bmimas and Foulest Codr)ar
Rut he I.ezeurp,therefrom and on,basis for she allegd exemption.Any violation of ..3SC� �N m Occupancy Type'
Section 7031.5 by Any applicant for a pemdt subjmu the applicant to a civil pmulry,of
not more Nen fvc hundred dollars($SX4.
1,asawnerofmcpma ny.mmyemployceawimwagesumciraalecompevutinn, - equired Inspections -
willdothework, d ano moon.is rant ourbodedd inriff fe,We(Sm.7014,Business
arta Prote s ors Cods:The Conua ors's License Law duce,not apply m an wen o/
property who builds or Improves thereon,ed who does such wank himself a through
his own employees,pm,idd Nat such improvements are not intended or offered for
We.If,however Ile building or improveman,is to within one yearof mmplstim,the
ower-builder will harc the burden of proving Nat he did not cin or improve fee pas-
pone of We.).
C1 I,As owner of dre property,.m exclusively contracting wish licensed contractors to
conateuct the project(Sec.7044,Summers and Profession.Cade:)na,Connector's U. 000
"me taw does not apply to an owner of property who builds or improves t emon,rod
who omtrwts far such projects wish•cmmctor(.)Nested pursuant to On Cmu bee. /
License Law,
(]IAmexempunder Sm. C
,B&Pforthis ream Anne,
Owner Dau N
WORKER'S COMPENSATION DECLARATION
I hereby affirm anti;pen.By of perjury one of Uro following dedamtiom: ,
ve and will mainuinaCeniOcere of Comenuo al6insurt for Workers Compen-
cation,r provided(or by is
um 3700 of she labor Cade,fa the perfonneae of the
wok for whim shim#emu,is iuued,
have aLa will Code
n ff Compensation fO, Insurance,Which
as required by Section
3]Ooof Ne labor Cde,for Ne pcdomunce of me work for wM1ich Nia permit is issued.
C Worker's Com enwi nu mcani and Poliryn ba art_ q
Carries Policy No.: 9 1
CERTIR ATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi.colon And!nor bemmplaudlrthm.,is foroahndred MIT.(SIW) '
or Ica.)
I certify that in the proff tee of she work for which this permit is issued.I shall
not employ any person in my manner so as to become sunset to the Warkers'Compen-
sation Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after meting this Cenificae of Exemption,yen should
become mbjmt to the Worker's Compensation pmvisiom of she Leiner Cde,you at -
foMwith comply with such provision*in this permit shall be dared revoked. .,
CONSDNCDON LENDING AGENCY
Q I hereby affirm Nat Nem is a conswetion lending agency for the urormwa of
y
On..it for which this permit is issued(Sm.3097,Civ.C.)
Lender's Name
C > Leder'.Address
fa] QI certify mat 1 have read diia application and mute tlut the above infomadon is
96 correct,)agree to comply with oil city and county ordinances Ad Stam laws relating to
building construction.And Tommy authorize msenWives of this city to enter upon the
U 0 -
above-mentimed pmpeny far inspection purposes.
foes E.. (We)Agra in ave,idemnify ad kap Womlm she City of Cupertino ageriut
fJ liebihoes,judgmcros,cosumd mpen¢s which may in any way aaneagalnst aid City
'fit Lg: in mron,eme of the granting of this permit.
[-� APPLICANT UNDF:RSIANDS AND WILL COMPLY WITH ALL NON-POINT
t..) SOURCE REGULATIONS.
Signature of Applimi/Cmdonor Date
W RDOUS MATERIALS DISCLOSURE
roll IN Applicant or future burning acupanlatae or handle cumbers nontrial Re-roofs
As defined by the Cupertino Municipal Code,Chapter 9.12,end the Health and Safely
Code,Section 25532(a)? Type of Roof -
❑Yes 7"'
Will she Applicant or furore building octopus,use equipment us devices which All roofs shall be inspected prior to any roofing material being
,dgft..t hmarchu,air mnumiranu As defined by the Bay Arca Ab Quality Management installed. If a roof is Installed without first obtaining an inspection
"c❑Yes t7 I a vee to remove all new materials for inspection. Applicant
�'a
Ih.ve rend she h.aardaua matori.B re9nirtmmts oder Chapter A.95 nfine oar- un erstands and will comply with all non point source regulations.
faro H IN&Safety Cade,Sections 25505,25533 and 25534,1 udersurul Nat if the
huildin
creation. atenam,that it is my responsibility in notify the occupant
rtyoi" net prow to is Cmificue of occupancy.
Signature of Applicant Date
caner udbonad agent Data
All roof coverings to be Class"B"or better
OFFICE