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00050012 CITY OF CUPERTINO PERMrr lqo. 'BUILDING DIVISION PERMIT CONTRACTOR INFORMATI N: �� Sib I,� BUILDING OUR ,,/�` as If L HeR l hoc DR • k SANITARY NO APPLICATION SUBMITTAL DATE e L � O ��g Vopfc rn /C CONTROL# ` C4 :CHITECf/ENGIR BULDTNO PERMIT INFO Foou A z � yid? LICENSED CONTRACTOR'S DECLARATION ' O Z ❑ 1 hereby aPorm the I are licensed ander pmvisiods of Cluipter 9(commencing Job Description f m is on iviyp3pglM1eLic.0 eaM fain n ;, azS� ,omit fmceande cL r(/...1L/1 me a Dow Common,s Co # i - O Dao Conuspu , ` ��� &O ARCH ECL N ///111 X. 1 rs y am shall w Public s C a foss, a =v, OWNER-BUMDER DECLARATION tz Q I hereby a%ism that I em"amid from Ne Contractors Licewe Law fm the 1'O following reason.(Section 9031.5,Business and Profusions,Cade:Any city m county m which require a permit an construct,Wmr,improve,demolish,or minor any summon Priot u.its issuance.Wso aquire,tuapplicant fw,uch pemut m Gleasigtudyampeu Sq. F loor r a ation that he is licensed pureuanl to the provisions mite Conmxrore License Law(Chapter 9 (commencing with Section]000)of Dilmon 3 ofthe Business and Pmfeuiom CWe)or tut he is exempt therefrom and the buil fm dm singled i u.Riot Any violation of 3G;4— not p Ocupancy pe Section 7031.5 by any applicant for.pemJuubjm,d,e applice,to a civil pemlry Of — - nm more then five hundred dollars($50)). ❑1'.. .,.(theproperly,mmyemployaawimw.gwutheir sole,.Nnaaawu. f Required Inspections will de the work,and Neetmcmm is trot intended moRwed for sye(Ser.]044,Bwiuu and Profmsiom Code:The Cow there License Law dal nm 1,hi s lf owmr through a� / properly who bunds or improves a crcon,and cove does such wwk himself Or Of 1 ' I /UUU} /..,'Lt/vj his own employers,'midW that such improvements sm not inm.dW m.Rercii for sale If,how ever,she building w improvement is sold within one year fcomplinhat'the owneebuldm will have dw burden of proving that he did not build or improve for pm- I� t�Il n h 11s1 au mvary ( +kms ' Il UY V/a� L So ❑1, nen of the Property,am exclusively contracting with bamW conuacmn - v, (unionconstruct the project apply ]094,Business and Py Win, w CWeO She C°nvutm',and cense Law dasnot applyman owner./progeny cove beddanrientmvw Conmeend ' JUN 0 4 2001 whLace fmauch projmu with a conwemr(s)licensed pursuanno the Canuacmrs License Lew. ❑Tem exemptundamsm. ,B&PCfm Nisreuon - y� p Owner Date ��/�16®Bltl'ul ' WORKER'S COMPENSATION DECLARATION I ureby affirm under penalty of perjury one of Ne following declarations: - 1 have end will maintain a Cmificme of Consom,elf-hoom for Worker,Compem ' don,as providedhhi for by Section 3]00 of Ne Labor Code,for the perfomuna of the (\1,11y1/I�/y�] k for which this panni,is issued. V ❑1 have and will mamuin Workers Compensation Insuwdce,w requimd by Section � . MY Laver Cada,fur Imp.turn athe work for which this pcnnit is iceeuW. �Q .. My Workers Compensation Insurance wrier end Policy numbv art: as Curler: Policy No.: y! - � CERTIFICATE OF EXEMPTION FROM WORKERS' 4.r COMPENSATION INSURANCE (This utti,m neW rant becompletW ifthe PenrW is froom hundred an,3100) m leas.) -' Icmif in Nape an eof wotkfor hickJh�e isi dl shall not i anY pars. in an nn` w .y1neN t°mac a re Compcn- `, Winn L 1. 0life in It Applicant NOTICE TO CANT: ,Wt r g it a roam of Exemption.you should No. a coin y i suchWedrs Compensation m this provision,of the deemed Code,you muss fwthwiN comply with such Provisions m this Permit shall w domed rmokW. CONSTRUCTION LENDING AGENCY 0 Q lureby offiran thatthereeac.mmelcul lending agency for the perfomunce of the wank for which mil permit isLSA ued(Sm.309].CtY C.) Lenders Name ai > Lenders Address W Q 1 unify that I have read the a,],claim and,mm that the above information i, . . .0.7. z correct.1 agree to comply with all city and county ordinances and state laws misting to C.) Obuild;.,cimenswuon,and hereby amhmen represenWivu of this citym enter.upon Ore above-mentionol property for inspection pmparzs. W r. (We)agree m and save,indemnify keep hmmless to City of Cuporom against Q f.) liabilities,judgments,cmy and cxpmuv which may in any way accrue egmi,said City - �W W in consequence of de,granting of this permit. H C"I APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT , V Z SOURCE REGULATIONS. - /1 Slifuume of Appl¢anUCmuasor DAo� HAZARDOUS MATERIALS DISCLOSURE Data Will the'.,Urmorfuture wilding occupantnom.r handle Wood..,Mo.. rud e-rOOfS .M defined by the Cupertino Municipal Cale,Chapter 1.11,and o e Health and Safety Cale,SmOoo 25532(a)P Type of Roof' ❑Yes No " Will themplicanumfawmbuildingmcupant us egaipmenl or ded.e,whish' All roofs shall be inspected prior to any roofing material being emitbueM.°•aireanumimnn as definW by the Ar Air Quality Management installed. If a roof is install 'thout first obtaining an inspection taree to remove al w ater' Is for inspection. Applicant oma ye . mann rCuprer6 Sof GW;. and d wi e m ly w' h all non poi. sourc regulations. .is Heal safety odei 05 533 ]5534.II if the idldmlidws mew mlyh arena yiti my 'esiblirym�at Ne cupan, ot c"m no bah t 'minis. eOf.Cenif�ig c o rnadm ildagent ,,,,) D = Signature of Applicant Date , All roof coverings to be Class"B"or better OFFICE