00040058 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: Q� , J
BUILDINGrA!DDRESS:' 4 _
DI SANITARY NO. APPLICATION SUBMILTIALL/DATE
OWIR�'.NAME:
�Jj NIC CONTROLls,
f
TONE: El
ARCHITECT/ENGINEER BOLDING PER MIT INFO
baa l� M� M� A
Z~O�_ LICENSED CONTRACTOR'S DECLARATION
I nenby,cera that 1 w licensed wader proviunm of Chapter 9(commencing Job Description
rr b C t�i with Sation T000)of Division3ofrW Busioesa wad Profeuiam Cade,ead mrlicemeir Q �J ///S 11 /Y n
4x � i emsefull orc<aadeRect. � �
Ey O License Clan Lic.M 1 /
aKj S LL Dale eOnVaefOr ) 1
f- O S ARCHITECTS DECLARATION � I A." O si
v�� I vndentaad mY PW>rIW l W used u public recada I I I
0 LJi Profeuimal
u�
OWNER-BUILDER DECLARATION
C 3> 1 hereby affirm than I am exempt from the Con moures License Lew for the f \ Pre. h 4— h 1 14 ✓J
S n following marl.(Section 7031.5,Business end Prefeedom Code:Any city a county
C$ which rryuim a permit b eme true,alter,improve,&.Jim,u repair any suucwe
e,a_ Sq. Ft. Floor Area Valuation
priorbitaisroanceilso.Ito ft ted apions offor sockpermit bfileseLaw(mtement
Nat ho is licernaed P.usuannotW provision of NeCwuatora License law(Chapter9 40OO Q
you
be I.exempt with Section 7000)of basison3 of the a ed mmad Professions Codc1 or
Sul io is btmrtfrom W the buns forub %the axmpeao.Any viotaeon of APN Number Occupancy Type'
Section M31.5 emli any applicant for a pemdt mbjau the eppliunno a civil penalty of O
more Uun Rve hmdaM dollars($3001.
Laeowa,ar,- Properly.armyemployee.withwage,..chaira.l.compensation. Required Inspections
7 03
wi Bothe work,ead Neewcwrt isnm imeadedoroRemd fm agile(Sa.76W,Busineu
and Professions Cade:The Conuacors License Law does.1 apply to an Omer of
properly who Wilds or improves thereon,and wed does such work himself orthroughfor /
his own employee Pmvidad thin such imp I.sold ta are era i emod.of
a oHerod for
We.If,howewithe WildingorimprovementIsne within oneyuraf completion,Sore
nW ilder will haw,the When of pavin6 Nu W did nm Wild or improve for parr-
Pose Uf s . !/ .
1.an owner of the propenY,am exclusively contracting with licensed contractors to
conswct Ne pmjat(Sec.7004,Busincaa sad Profusiros Code:)lime Conwclors V- �r
came law d«a ort apply b an owner of property seed W iIN ar improve tWrcoo,W Q
seed wntrats for such molau wilt a cwtreclor(nl IiceruM pursuant o Su Cantratm'a ,/�
w.
❑lame mpsuMer Sm .BdPCfor n ,
Own. Dar /d OJ
WORKER'e COMPENSATIO DECLARATION
by affirm under penalty of perjury one of the following daluatiom:
w and will maintain a Cenificate ofConaent to wl4iasurn for Wodees Compero
i ration,as provided for by Section 3700 of the Labor Code,for the Performance of the -
work for which this permit Is issued.
❑1 have and will maintain Workers Compenwion Insurance.as required by Section
3700of Bre IaWr Code,fa the pufwmance of the work for which thin Permit is inured.
My ovmi ars Comana nion Inmrarue carrier and Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sarionneediof becumpteted if,hepeamit ie fearoalmew it Mi.T$100)
or less.)
I mnify tot in the performance ofdre work for which this permit is issued,l shag
ort employ any person in any manner so as to Wwme subject to the Warton'Compen-
anion law,of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
became mbjat b Ne Works.Cmepemation provisions of the Labor Code,you must
forthwith comply with mch pmvit im,or this permit shall W dared raked.
affirm
LENDING AGENCY
0 I hereby arm that them iso conatmcthm leading agency for the perfmormor of
z y Ne work for which this nom",
is issued ISa.3097,Civ.CJ
L.Lader6 Name
cm > Leaders Address
1:7 Q 1 certify Nu 1 have read thio application and cute that the above information is
Cw c o ct.I agree to comply with all city and county ordimnces and sine laws relating to
.'7 Z building cmetrucimi.and herbyemhorice repteammaivnof this city en a......the
V C above-mentioned progeny fa inspection purposes.
kr. r. (We)agree b uvc.indemnify end kap harmless thatCity of Cupertino against
0 U liabilitiesW,judgmenWain and npemn which may in any w,,.ccme..aunt said City _
a in conu9uence of Ne granting of this permit.
ILr APPLICANT uNDERS"I'ANDS AND WI LL COMPLY WITH ALL NONdY)INT
L.) CERPAULAT S.
Oof ApplicanVContrDO Due , O
HAZARDOUS MATE IAL.DISCLOSURE
WillydueCuertino cert Wildinge,Chapter
nsmor handle humdousmoteety Re-roofs
u defined c Section
ted Cupertino Municipal Code.Chapter 9.12,end the HWth and Safety
core,ween zs332(.r. Type of Roof
❑era �t No
AM
Will the appliceat or furore Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit heutrdova ev conuminana as defined by the Bay Arca Air Quality Management installed, If a roof is Installed without first obtaining an inspection
"' 1 a ree to remove all new materials for inspection. Applicant
❑Ver !1.1J0o
IF
Mwerud Ore huudou7e\materidnrcgaimeanrata minder Ghaaer693oaeG.li- un erstands and will comply with all non point source regulations.
forma Health&Safety Code,.avoru 753U3,z3333 and 25334.1 uad.nuad that if the
hodoes ot currtmly have a twill,that it is my naporsubillty m ratify the occupant
7.f=wwa.
enta which run W ran prior to iuuencc of a Canificau or thcupuwy.
Signature of Applicant Dale
Owncroraugmriz.d agent Dau
All roof coverings[o be Class"B"or better
OFFICE