00020197 CITY OF CUPERTINO - PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 000 ) LC
BUILDING ADDRESS:
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K Or /'T 5. <nTlAn SANITARY NO APPLICATIONSUBMITTAL DATE
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OWNER'S NAME: ..rj Mlp4
J N/C CONTROL#
8 PHONE: �8� Y$� 16V '�KLI �� Ll \ 1 J \OS� .. ❑. / 6 I O
ARCHITECT/ENGINEER - BOLDING PERMIT INF
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LICENSED CONTRACT'OR'S DECLARATION
1 hereby aRmr tat 1 am licensed i n ss provisions of sC ter 9 rcommensin
oz-❑ w g pD .�/_,_ ,tT �.-r` tib Description\
F=�� wise Section 7000)ofDivixion3ofNe Busiaaean�asio�Cade,aMmyli«osis �'KJp►' r Ja
�zFa,Q in full tome and eR<c� ` 5�
Uceme Claax Uc.#
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DeARCHITI"S DECLARATION
ECL ARR ION
1ue yIPublicromema
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OWNER-BUILDER DECLARATION
I hereby affirm that 1 em exempt from Ne Contractor's License raw for the
Sa O following reason.(S<aion 7031.5,Business and Professions;Cede:Any city ce county
a _ which""res a permit m thaw",ame,improve,demolish,or repair any awcnue - S Ff.Floor Ar a Valuation
poor to its issuame,also romm.Neapplicant for such pemm t file.minni comLl• Y ment V w
that he is licensed Postman to Ne provisions of Ne Cumbcmf6 License Law(Chapter 9 O
(commencing it Section 7000)of Division 3ofm<Business and Prof aaiom Code)or _APN Number
�.
to he is emorm merefrom and me basis for m,aneged eannium..Any vfomtlon mf Occupancy Type
Section 7031.5 by any applicant for a permit subjects me applicant to a civil Penaltyof �s
not more ten five hushed dollars(SSW).
❑ Lae owner of me mopeny,amY employee wit wegesa Neiraolecanpemulon, Required Inspections
r will dote work,and the elmclure lana inteMedoroRertd for We(Sa.7814,Business -
and Proferwor"Code:The Commmou'6 License taw it.na apply to m owner a '
property who builds m ima Provthereon,and who does such work himself w through r
his own employees.Provided mat such improvements art act intended or oReral for
We.If,however,me building or improvement is sold within one year o(complembi,the /
-Wildtt will have the burden of proving tet he did not build or improve for pm. /
❑L a tt
compact Prm emte Sac 7041,
0amBusiness
and Profession,ntrsnCwoitdeI:l)cTeoheeeC Contractors
whme law does an apply to on iwnr propert,isisWilds or improves and
who contracts for each projot with a contractor(a)licensedNorman in me cumbacmie
UmLsssw.
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arra cxcm lu rSec. ,BRPCfor his rtuon ..
Dea
WORKER'S COMPENSA N DECLARATION -
-1 hereby,/firm under pastry of perjury one of me following d«lantiom:
❑Ihevc endwill mainteinaCertifcam o(Comem ro col(-insure fm Workers Compen-
sation,as Provided for by Section 37W of to Libor Code,for the Performance of the
work for which mis permit is issued: '
❑I have and will maintain Worker's Compensation Imurewe,as required by Section
3700 of me Labor Code,for me performance often work for which tis permit is issued.
•My Workers Compensation Insurance carrier and Policy number are: -
Cartier: Policy No.: -
CERTIFICATEOFEXEMPTION FROM WORKERS' t
COMPENSATION INSURANCE r
(This satian need not becomplaed ifthe lonnitis forms,hundred dollars($IN)
or lees.) _
I certify that in the perfortnence of me work for which this poseur is issued.I moth
not employ enyp"' nanyma s bcco odurs, b
mtcWorre'Compes-
mtimn"a""O
aweofCalif(_ _
Apim /JQ ,fl
NOTTCETAPPLICANT:If,dor mekin8 ria Ceni am ofi� Bxempti�,ymo ahoulA
.become subj«t to the Workers Compensation Provisions of me Labor Cade,you must
forthwith comply with such provisions or tis Permit doll be deemed revoked. ,.
CONSTRUCTION LENDING AGENCY
I hereby affirm that mea is a co mussoon lending agency for me perfomaoce of
ti -the work for which tis permit is issued(Sec.3097,Civ.C.)
Fy Landers Name I have rev�
Lender s Addres
- 1 cs l
[i7 A ertify tat reed his application and sum that me above infamadon is
r 1
;:Iz cares.I agree to comply wise ell wh county ordinances and side laws relating m V
U O building consvucuon,endhereby audmrria rcprcanmliva of mis city to eraser upon me
abovementioned Property for inspection purposes.
W Ey (We)agree to save,indemnify and kap harmless the City of Cupertino against - L
0 U lubilities,judgments,coataand expenses which may in any way acme against said City ' r
i>4 W in consequence of the granting of this permit.
r a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS. �'
9s I�A1�4 -76 P— AA/7 &&Ace.;
'gmturcuf'Applicant/Conuacm!-ra�Wl Date
HAZARDOUS MAT4ALS DISCLOSURE
Will me applicant or loom budding acupantame.,handle havodoue seminal Re-Iroofi I '
as defined by ha Cupertino Municipal Code,Chapter 9.12,and me HWt and Safely
Code,SecOon 0537(D7 Typeof Roof '
Will me applicant or future building mcopam use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit harandous no comamimkms as defined by the Bay Area Air Quality Management installed. If a roof'is.installed without first obtaining an inspection
°`e""' I,a ree to remove allnew materials for inspection. Applicant
❑YesNm g p pP
IMv<rcad the h.rarora,memdah rtgnirtmenu ander Chapter 6.95 of to Chli- understands and:will comply with all non point source regulations.
fomu building altdoes o Safety rre Code,Sections 255U5,25533 and ns hifi 1 to derstandnotify m that if Ran
�� _ r
of he bourn;
na currently hast a Rural,mait is mY asponsibilirymnaifytepancy.emotion (Tr/
of the rtyuirtn which must be n Trion'.iseuaae of a Cenificae of Occupancy.
�� Si a re of Applicant . Date
Owner or rized,gem m
All roof coverings to be Class"B"or better
OFFICE.