00030056 CiftY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
(9903006-6
BUILDING ADDRESS: //)T la n �n• // SANITARY NO. APPLICATIONSUBMM&LDATE
05/5 . �QO/%IJl l/ (iuL( / (, 7
GW ,6 °V 253/ iryftlP/l/�xl Aye
N/C CONTROL#
R' �f3 25�-082 GJG/1 ei9t 1 M 9/��'07 ❑
ARCHITECT/ENGINEER,- C�1 � �/, CBULGING PERMIT INFO
�Z6 r
Z h i LICENSED CONTRACTOR'S DECLARATION
I hereby amen Nal 1 am limmed under paviumas of Ca ed vd
o z-o mer 9( a o Description
Ii Pe in . with Section]000)ofDivisian 7of da Buaiaeean Prof iouC ,andmy
z'cin full force aMCRat
S il:O i U LimineCon
G Dau I understand my plansCHT ebe 7S DuLARRA
Cpublic ucords /'VplN�af W"�/ ��_•/
i O
Limited professional
¢I OWNER-BUILDER DECLARATION
t 3¢ 1 hereby affirm that I em exempt from the Contractors License law for the
S C following reason(Se lion 7031.5,Business and Rofeauons Code:Any city m calmly
3= which requires a permit m consumer.slut,improve.&=Jim,or mpau any scomme Sq. FL Floor Area Valu/est/I
from to its issuance
,also requires me applicant for such permit to rile a signed sutement D V�
that he is licenced pureuam to me pmvisionsof the COneacmb License Lew(Chapter 9 v
(commencing with Seetion7")of Division 3 o she Business and professions Codeine AFN Number p yTyp
Nal M is exempt d n'limm and the basis fat she alleged exemption.Any violation of n OCCU anC e
Section]031.5 by any applicant fora permit mbj.0 the applicant to a civil peulry of
nm mom N .San five hundred dollen(3500). v
l.umnerof Nepmpeny.ormyemplwmswiNwgesu Meiradewnipcasatfon. - - Required Inspections
will I' Newour CetM stmcmrcianas Lt.dmoflrrtdsther ly 4.an
a
and arty who
Cade:The,Camr%nmi Lianas law doe.rant apply s lf owner of
his own who builds or improves,such improvement,rod who does such intk deed or or mmugh
his own employuvxcv"are provided them arch enttrdw ace nm intended m officred for
role,If, ildevw Onebuildingoren of proving
trend for tM
rcr-builder will have da burden of proving that he did not bulb m improve for pro- /
you of selene /
El I,u mvner of Ne property,,B exclusively contracting with:)Din Cwnuacmrs t-
consuuct me project(Ser.]04x,Business end Py wlv i i Code:)The Comramor's Li-
w oro taw ds formepply m an with
a o(pracum.who sed purr improves drtew,and /
who contracts fasuch pmjecu with•conuactm(al licensed pursuant in the CenratMa v
License IoW. /
❑lam exempt under Sec. ,B&PCfarmia neuon
Own. Dau
WORKER'S COMPENSATION DECLARATION
1 hereby amrm under penalty of perjury one of Ne following dalasmuu:
j I Mve and will mainum a Cenitlem,efC.,an self-insure for Wmkcm
raCopere-
inion. provided In,by Section 3700 of me Labor Code,for the performume of thc
a which
this permit is issued.
a I have and will maintain Workeu
rs Compemlon Insurance,u reepund by Section
3]00of the labor Cade,for the perfmmmae of drc work for which oris peissued
.C.
is issu .
C.My Wohl}CompyLri
eeunu atticyhlulPolicy nyrgppyare,� /y .
CERTIFICATE OF EXEMWION PROM WORKERS'
COMPENSATION INSURANCE
(This section need nm be completed ifthe permit is for..hmdrsddmllars(3100)
or leu.)
1 minify tat in the perfomunee O/Ne wink for which this permit is issued,l shell
not employ my person in any Wenner an as to become subject to Ne Worker'Compen-
ution Lawsaf California.Date
Applicant
NOTICE TO APPLICANT:If,afar muting this Certificate of Exemption,you should
become mbjmt to Ne Worker.Compnation provisions of IM labor Code,you most
fonhwde comply with such provisions or this permit mall W deemed revoked.
CONSTRUCTION LENDING AGENCY
0 I hereby amrm Nat Nene is a construction lending agency for me pRonrurme of
me work for which this permit is issued(Sec.3097,CO,C.)
Fa lander.Name
�i > Lenders Address
f:7 Q 1 anlfy Nat I have nod this application and gone met the above information is
�scone.I agree to eumply with ell city and mum,mdlnaems and Bute laws missing to
U Obuilding comwction.and hereby authorise representatives of this city to Inur upon the
above-mentioned papery fee inspection purposes.
IT. E;, (We)agree in save,indemnify and kap hameas the City of Cupertino agehut
0 t.7 Iubilitia.jWgmenrs,coque dexpenus which may in any way same agunn and City
�a W 'm mmVi ucoccof mM Sinn' f di permit
f+ APPLICANT BNDERSI I )WILLC PLY WITH ALLNDN-all
V SOURCE REGULA W 4-1<ry
Sigmmrt of Applicant/C ere
ATEMAIS DISCLOSURE
wBNeepplicantorfutun ildingoccupenutmeorhanNehamodommererial Re-roofs
u defined by the Cupertino Municipal Code,Chapter 9.12,and IN Health and Safety
Code See..V5320)] / Type of Roof
❑Yea Ne
Will an
ll tit applict m"Ou"building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
'mit hasardou air controm seas eBlind by the Boy Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
❑Yes o
I agree to remove all n materials for inspection. Applicant
Ihave mad me MsaNuum mauroeh nem imine .der caper 6.95 of me Cul- un erstands and w' omply with all non point source regulations.
forma Health&Safety Cade,Secvans 25505, and 25534.I understand that if the
hilding does red eunantiy MveaumnLth sWyrespomibiluytuom yth ceupam f//)
of Nrrequhemmu 'ch moat be me or m:smemofaCmiOare Oce
IF I Owner ar.rthoroar int Signature licant Date
All roof coverings to be Class"B"or better
OFFICE