00100140 cl D; G DIVISION BUI PERMIT CONTRACTOR INFORMATION:
'
• oun.DING ADDRESS: - PERMIT NO.
OWNER'SA P.. APPLICAT
PHONE: .- 2 I' EENS SANITARY .NO,
ARCHITIXT/ENGINCER: _ — ✓ BUILDING PERMIT INFO
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LICENSED CON'TRACFOR'S DECLARATION
z 5 y= provisions lob Description
O Z_C 1 hereby nlBrm mel I oro licensed antler pmv sof Chapter v(a+mmm�cing
r w_W with Sechow7hdd)ot Dlui.innJyy(rIhcflresinesnnJ lhofsbins'Ctdaand mylicese
ca f sc is in full force ant�fllira. 7 2 ^ .
xWSLQ Data lass Lic.p C� 4.L REMOVE SHAKE., INSTALL 1/2" OSB &MONRE—LA
p Data eomntctm
r a O v ARCHITECT"S DI[CLA A'1'ION
I understand my plans sbull he used as public recoNs
xGE
i S O O License)Professional
X=u that I a .Bienipt fr DECLARATION
W^_,rt 1 hereby.(Seta nl 1 exempt from the Contractor'sCru :Any c t.vte for the
F X_0 followhich reason.Parmt(Section 7031.5.tm Business and Prowe,tea al i tsle:Any oily oseamy
ts-= which require a permit re mnamm,alter,impm e,demolish,nr repair any semens ,
322 prianoslicenance,also dlums..11.be
theapplicant for such Characters
License ae
Lear(ned m¢mcnt
that he is licensed pursumnmtw pro Division
of the Contractors License m,Nan,Code) Sq. FL Floor Area Valuation
(commercialtemp Section]11(18)of Division 3o thellusinnsand i.a.A.,li lthim
.,,but he is 3LS b Therefrom and me basis for the allege)exemption.Any violation
of Station]m n iv any applicant for a Iermit sahjccls the applicant w o civil Penalty
of not mare man fi,�e handed doua.(ssw). y APN Number 0CCNaTMpe
111.as owner of the property,m my employees with wages us Their mle compensation.
will do he .,it,and the structure is not intended or offered for sale(See 7144.
Business snit Professions Code:The Contractor's License Law does not apply to an a sr • LNequired Inspections
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements am not intended or
offered for sale.If,weever,the building or improvement is sold within one year or 305 — FRAME'
iompletion,the ownervbuilder will have the burden of proving that he did Dol build or
mprove far mi of sale.). 307 — INSULATION
01.as owner of the property,am exclusively contracting with licensed contract"to 601 — ROOF TEAR OFF
construct the project(See.7844,Business and Professions Code)The Contractor's
License Law does no,apply In an ownmor property who hi his ,,improves Hereon, 602 — ROOF PLYWOOD NAIL
and who contracts for such proiecrs with a contramoas)licensed pursuant to the 503 — ROOF BATTENS
Contractors License Law.
❑I am exempt under See. ,B&P C liar his reason 604 — ROOF IN—PROGRESS
Date .
WORKER'S COMPENSATION DECLARATION "
T hereby afrwill maintain
PenaltyCeni perjury one of vert to self-low ing im declinations:
War
❑ 1 have and will maintain f Cby mane of Cement to nc Labor 11sr Worker's
C performance
o he provided for by Section Jissu of the LUM1sIf Cmlc, for the
peAnrmnnce of the work for which this permit is Issued. /
❑I have and will maintain Wader's oompont,onn Clio
work fi us which
thi by rnat is �®
01N1 0l the Labor Cadc.for re is C n lsovi of the work fin required
this y Seat s i'vo, lllp0_
sxueA Wo kcr,,Co penr(s�t/µn InsuranceaZ (Init Policy number are:
1�
X Carrier V ' Pnbcy N W tC
CER'I'1I'ICATION OF 1?1(EMPTI(1N FROM WORKIiRS-
COMPENSATIONINSURANCE _
(Thisscedon m¢d Dat bn completed it he peril is lav one hundred dollars
($100)nr less.)
I certify that in me peroarr nnee of me work tar which this pmnll is issued,I
- shall aur employ aay person in any ironer so Its to become subject to tea Waders'
Compensation Laws or Culilivnia.Date
Applicata '
NOTICE TO APPLICANT:IL almr making on,Ccrtilwana ur L'smnptin r. ,it,should
become nu dater m the Wnrkera Cmunnfer, t provisions of the Labor Cods,you mast
O fnnhwith comply whh.such Provisions or pis parmil shall be Jcenmd rcvokssl,
z
F^ •N-t CONfi'areiia 10NrLENDING AGGNCV
a I hereby whati mi,thecae ies construction(Sir,
Icnding agency liv the Pcrlilmmncc
Gil
Leader
work for welch pis permit is Issue)IScc,11n)],Cis.C)
z Lender's Name -
� Z Leader Address '
0 1 certify that I have head this application and state mal the above infnrnrnion is -
E. correct.1.ghee or cxnnply with all city trod county nNinmmes and suet laws relating
Q [) rebuilding construction,and hereby nummice representatives of this city to enter atom -
ry the throve-mentioned mPar y for Inspection prrp.sa,
E„t 0. (We)ngresmsave,' damnify and keep harmless the City of Cupertino against
W liabiliti x, ad a.
c an to,am es which may in any way accrue aquina said
U Z City in of quence of 1 gm ing of Thi - til, c—� t,�c�� /
r •.t OU I. LEISp'1 LL COMPLY WITH LN POI Issued by: ` Dat/
O � �ll� do
n are J`AppicalaXomtData Re roofs
HAZARDOUS MATERIALS D1:1Widths,upplicam or Tamm building recuPam store slamor nr handle hmNm
uamaterial Type of Roof -
C defined by the Cupeninn Municipal Cole,Chapter 9.12,unit the Ilcahh and Safety
Cute,Section 25532a)] '
Ores ON. All roofs shall be inspected prior to any roofing material being installed.
Will the al,plicamor future Indiingsecupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove -
emiil
It"o rdo
us air conmmiwms as defined by the Day Managementa Air Quality Management
Rmim?ver Oen all new materials for inspection. Applicant understands and will comply with
all non-pont source reg`Ilations.
I have real the hezadous materials mqui arents under Chapter 6.45 offs 1 j
California Hwbh&safety Code
olons25505.]5573 and 255]4.1 understand lea \ ,IG//
if the buildi Jros nm currta tenant,tea it is my rcxponsibility m notify the
mecupam of quircmenltact prior m insuanc of o C fiesta ofcuPanq. Signature Or Applicant Dateoxe .gem ' Date All roof coverings to be Class`B" or better .
OFFICE