00030026 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 000-656 o
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BUILDINGADDRESS: �
SANn'ARY NO. AAT)ON SUB�T DAI
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NIC CONTROLg
ON:: 3 - 4 2 qt Aa, L 3330
ARCHITEC IENGINE:ERO� oa — Z'
Z. BULDING PERMIT INFO
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H V i LICENSED CONTRACTOR'S DECLARATION
i=9 I herby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
F vt(-,u. w,NSmtion7000)of Division3of NeBusimasa Rfesiom Code,u mylimmeis
=y w j in Nil force it ly C D if
re < lluvs` .1 .
"RYJ Ve.» o '/ rte
3 u.��, Dna` Convutor W✓Y' _ y/ O�/,
-O ARCHDECTS D£C ATL /// ! / V ✓
v�i 1 undenund my plans shall be used as public s
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y E'o
Illaad Parkark ml w R yi[eOWNER.HMDER DECLARATION
1- < I herby affirm that I em exempt from the Contractors License Law for the
F O following ramon,(Section 7031.5,Business and Professions Code:Any city ar county
aw
C a which requirm a permit to comwn,glees,improve,demolish,m mpav aay,swrnw i m S Ft. Floor Area 2 V luation�
pritN is
requires theapplicantfor coM1pemtiuofile aicar signed amcmem tl'
Nat he is licensed pursuant m dte provisions of ds contractors Licrnse taw(CM1ePa 9
(commencing withSection'KiNf of Division3 of the Busimn me Profesuou Code)a
Wt he is exempt therfrom add den basis for than alleged anorption.Any violation of APN Number Occupancy Type
Section 7031.5 by any applicant for a Permit sublecr the applicant to a civil pmalry of —
ram mom Nan five hundred dollars($500). 3(. Z Q /L
❑I,.sownmidezMalady.amyemployemwithwagm.ntheir mincompematia., Required Inspections
willdr Nrwork,and Ne structure is nm intended oroRcrd for We(Sa.7W.Husincra
al Prefesum oCode:TM1e contractor's la
ror's Limw dues am apply m owner
an
uof
property who builds or improves thereon,uhd who does mch wart himself.,through
his own employees,provided Nat such impsommenu art oat intended as offered far
fele.If,however.she building he Impeavemem band wittinane Yearaf mans lmia,Or
owmrbuildm will have,Nn burden of prising that he did nm build Or improve fa pm-
poweofWe.).
I,as owner of the property.mexclusivelysne and professions with:)Thelicensed contractors
-
se La the does
apply
]luno Bunions rad property
whobui Code:l The confeamars u-
cense law deco ort apply je ts owner of pmpeny who builds in seimproves duamon,u's
License acs for each projects with aconvactor(a)licensed pursuantm Ne Contractor.
0
License Law.
❑Iunexempt undo Sec. ,B&PC fm Nix mason
(3wmr Date •�"��I
WORKER'S COMPENSATION DECLARATION f1
i hereby dorm under penury of perjury one of the following declurimer:
I have and will muntainaCenifwr of Comem to self-insure fm Workers Compcn. l l )tl
�rn, r provided far mi Section 3900 of On Labor Code,for the per(omunm of the f, 1 1�
k for which this pemut is l.d. U l IJ jlt
1 hove and will maintain Wmaerr comprfam ofths,w ds forwh.h his pradu i Section
900of the labor Coda,to the prrformmmt and
wort fawhich this permu is issued. pIt ISR 0 {
My Worker'sfompeggatian lnsurucecurierand Palisyp�bma�aaf�
Carrie: C..Ala rt Policy OM 1 M.V J 1
CERTIFICATE OF COMPENSATION
INSFROM WORKERS' _
COMPENSATION INSURANCE
(This section wood not be completed i(the permit is faorchurtleed dmlam(5100)
ate less.)
1.y my Nn lathe pay..one,
of the wok foo hichsubject
this the W is loved.I shall
not employ any Caron a.my manner so u m become subjecs to the wrhers'Compete
moon taws of California.NO,
Applicant
NOTICE TO APPLICANT:If.Nes making this Cenifcate of Exemption,you should ^..��
become subject to Ne Workne,Camew
ption Footman,of the taho Code,you must L5 ,
f nihwilh compfy with such provisions ar this permit ball W deemeA rvokrd.
STRIID r j n ,1'1 I p tt hI
CONSTRUCTION LENDING AGENCY 't}5 Illi- U L7 V
Thereby efrrtn Nay than is a comtmedon lending agency fa the perfomwsc of
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the work for which Nis permit is issued(Sm.3097,Civ.C.) ' O q g000
Leaders Name ' MAR A L I
G( 7 I-andrev Addre.n �i 1
W ^E I cenify that I have read this application and SWC that
at the move information Is [f
5 z contact.I agree to comply with all city uN county mdlmneen andsur laws rtI.,to
U O Wildingcmufeuction.and hmh
eyaof
uthodacts,ammmives this city to enter upon dr
cove-memianrd property for inspection pu, as. �y
W F (We)agree m save,indemnify and lamp humless the City of Cupertino agaimt J
C) („) liabiliues,jndgmcnq couaMespemcs whichmayin my waysccaue.gumt mid City
,Y W mcalsequenm of Ne gaming of Nis permit.
F 6' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
Vi
SOURCER'GUI.
40
Signuo A nntna ct3,I
uroDm,
ZARDOUS MATERIALS DISCLOSURE
Will theapplicamrrfmur Wildingacapem saareofhaMle harnrdoua m.rrial Re-roofs
as dermd by the Cupertino Municipal code.Chapter 9.12.ead than Health and Safety
Cadaseca..0532(a)y Type of Roof
Oyes ON.
Will thr applicant Of future Wilding Occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
't huardaus mr conumimnu to dermd by the Bay Ara An Quality Managrment installed. If a roof is installed without first obtaining an inspection
sne7
❑Ya ❑Nr I agree to remove all new materials for inspection. Applicant
Ih.,aread the a,drtem,terial.reasm ernsm,darchaptr6.95ofNao,h. un erst nd nd will comply with all non point source regulations.
forms Health&Safety Code,Sections 25505.25533 and 2.5536.1 understand that if the
Wilding docs that cumnly have a tergal that it is my responsibility to notify the Occupant .f
of the sequhemenu which muse be,met prim to issuance of a Certificate acmapuxy.
Signator f Applicant Date
Owmr or audmnand....I Date
All roof coverings to be Class "B"or better
OFFICE