00040172 CITY OF CUPERTINO PERMUNO.
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION:
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/OL�/p/O ✓DU{�1'Jq��`//I/IIV/�'^ /./ r5// /Jf�JJ, rL //// f/�f�j/D _ SANITARY NO. qP@LIGATION SJIB�AL DATE
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RCHITECrENGINEER
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HULDINO PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
_oaiore ❑a I hereby laRrm thasio1 nam3 licensed
icenseud under
ndseeraprovisions
siof
m Chapter
Ch adsee,ra9nd cmoymlmiaenncsein i
ss �(JJob�Description
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LiceeCles 52 Ln /-
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u, 'pate Cwoacmrpl���
Li O ARCHITECT'S DECLARATION
v�< 1 undenrand my plans shall be used as public mcoras '
i i Licanxd Professional
OWNER-BUILDER DECLARATION
CS ax 4 1 hereby aRnn that 1 am exempt from the Contr rma's License Law for the
N E❑ following reason.(Section 7031.5.Susicess and Profasiam Cads:Any city or wunty,
which requires a permit m comwn,alfa,improve.demolish,or raper any snucturc .S Ft:PI007 Area VdIUatlOn '
Prior t0 its issuance,also requires the applicant for such permit to file a signed summers q'
that he is licensed pursuance the previsions of dm Conbacmra License Law(chapter9
(commencing with Section 7").f Division 3 of the Bull..and Professions Code)or -
Ihm he i,earmin thaefmm and the basis for the elleged exemption.Any violate.of A��yP••-��ssfN Number - Occupancy Type
Section 103L5 by any applicant for a permit subjects the applicant to a civil penalty of 3S�_ - O�
not mom than Ise hundred dollen(3500).
❑I.ssow.aerthapropery,ermrempleyaxwithw.gaa,their..lewmpem.tion, -Required Inspections
will do the work,and the structure is am mounted or offered for,We(Sec.1014,Business
arra arty who
Cade:The Coneves thate License w Ides does not apply s if owntt h - I/
Property who build,or improves thereon,end who don such wnte himself or through
hisW own employers,provided thin such improvements within
uta ironicompletion,
a offered for 0
Mle.If,however lhc building aim pmrcmsnt if sold withintbuild improve
le fo,the 0�
owner-tabx)r will bare the burden of provin8 Diet he did not build m improve for Pur-
' you.seal 7. o/
❑L as owner of e, Pro.704.l exclusively conhacti.g with licensed conuans.U. -
cense La the projen(Sec,IOM,Business and Profusions Code:)The es Cher in, red
cerise Low does not apply je an owner of prepayy who builds or ant on are Norton,and - '
ss
who common,Law for sech projects witharontracta(q licensed punwmm are Contredor,
Ell ocr law.
❑I em exempa antler Scc. .B&P C far this rtsson r ll -
Owner Dam
WORKER'S COMPENSATION DF.CI.ARATION
I hereby affirm under gentry of perjury,one of the following declantiom: o
IM..d will nmintain aC nifLcate orComent m ulfdn&ma for Worker's Compen-
tion,es provided for by Section 3100 of the Labor Cade,for the performance of the '
k for which this permit is issued.
Ls,4t,'��1,have and will omimain Workels Campers tion Insurance,as rcquiud by Section
.M,
of the Labor Lode,for the perfomnnee of he work for which this permit Is Issued.
My Wkey
or '6 C upyp"angn Inxurantt curia and Policy nu
Carrier: /.J�N'/M /O!/ Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - -
(This section need net he completed if the permit is forms hundred dollars(SI DO)
a less.)
I verify that I.On Infinit of the work for which thin pemit is issued.Tavel]
trot employ any person in any mammy so as to become subject o the Worker,'Compere-
Mtion Law.of California,Data -
Applicant
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should -
become subject to the Workers Cm mastim provisions of the labor Cod,you most .
forthwith comply with such provision&or this permit shall be dexmed revoked. -
CONSTRUCTION LENDING AGENCY
0 0 Ihembyufbtmthmthen iv constmedon kmling agency rot the performance of _
the work for which this permit is ia,ued(Sec.3(99,Civ.C.)
lander.Name
IY Leader's Addns.
Is7 A 1 certify Nm 1 have read this application and nue that the above information is
Cw rest.l¢goon to comply with all city and county ordinances and state laws relating to
U C wbuilding construction.and hemby authorise mpreserrutives of this city to enter upon the '
ahosamanimed property for inspection purposes.
W '�y (We),Fee to save,indemnify and kap humless the City of Cupertino against -
V lubilides,judgments,costa and expenses which may in my way amore against said City
^fie W in c.n,a,.ca,e of the granting of this permit
ti APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT r
V 7 SOURCER^CULATIg4g,
Gl t `L
Signature ofAppli VComre<t pare
HAZAR 3 MATERIALS DISCLOSURE
Will thmpplicarm.r future building occupant smreor lunate hoard....aurid Re-roofs
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Cm,Section 2$532(.)+ " Type of Roof
❑Yes An
Witt the applicant or future Wilding occupant use equipmem or devices which All roofs shall be inspected prior to any roofing material being
emit herardoue air conomi,unts as dcgned by the Bey Arce Av Quality Managemem installed. If a roof is installed without first obtaining an inspection
g
a I ree.to remove all new materials for inspection. Applicant
❑Yea .
Ihave read the harard.a,m.�ials rwaimmsnn miler Chapter 6.95 of the Cali. understands and will comply with all.non point source regulations.
forma Health&Safuy Code.Sections 255(125533 and 25536.1 understand Ihas if the ,
building dasnacurrtntly heveamnent thnitismy nsponsibilirymndify theawpant �� � _Ila®
of Ne i�ma mum be met prior m u,ueae of a Ccnifirete nL&cupagt� '0 Date
Signature of pplica Date
owner or aero agent us
All roof coverings to be Class"B'•or better
OFFICE