00030160 CI fBUILDING DPERONNo CONTRACTOR INFORMATION: PERMr
PERMIT 000301 �,OQ
BUILDING ADDRESS: '
714 /, d yr Amli)0Jp�4/'Ne/(r/i`11L4V/& 4C SANITARY APPLICATION
LDATE
S NAME:
G D
NIC CONTROLg
'ZION;:: Sn� Tb Jti' �+•. I J� ��
ARCHITECT/ENGINEER YOIpt 9s/� Y7/7 BULDINO PERART INFO
SCO J
ub
Z LICENSED CONTRACTOR'S DECLARATION
O z—p 1 hereby eHrm Net 1 am 1¢rnsed uMer provisions of Chapmr 9(contmeaing Job Description
m with Sation]000)ofDivision3of the Business and Pmfeuj'an Code,arWmylianuis /� )
�Inein Poll torzeaM —/ 7�
c G Llunu Class L,c. y,L� t' (L, �,Ac /'Y•/G
n y Date Contraror 6 -
C�+.0 o" CHITECTS DECLARATION
1 undersraral my plans shill he used as public records
aa p O Licensed Professional •
µKi OWNER-BUILDER DECLARATION
3 a I hereby affirm this,I am exempt from the ContramYs License Law far the -
H p following...(Section 9031.5,Busineas and Professions Code:Any ciy or count' '•
w which requbes a permit m commuct,alter,improve,denwliN,or repair any structure
a_ Sq. Ft Floor Area Valuation
pornoslicensed porron,to to thovisiosoffor such pute's Lulea.igned w(Cha mem �O QJ
Natro is licensed pursuant ro the provisions 3the eBiadirore License Law(Chapter
(cam els exewiNSatioin fined)the
basis
ar oft he Business roti Profusions Cade)or APN Number Occupancy Type
Nat he is exempt anrefram and Ne beers for the Waged exemption.Any violation 01 ./ l 4 p Y
Section ID3L5 by any applicant for a 013). subjects dm applicant a civil penalty of VS /`%•
nm mmre Nen fire hurl d tlollen(5500). '
❑Las owner errthe propenY•or mY employem with wegesuJOv role aompensetian. - � Required Inspections
will do Ne work,and the structure is not intended or offered far We(Sec.7616.Business
aM Profeniom Code:The Contractor's License Law does nes apply to a owner of
property who builds or improves Hereon,aM who does such work himulf or through '
his own employes,provided thus such impro,..1,ere nest intended on offered for
sale.If,however,Um building or improvement is sold Marianne yearafcompledon,the -•
owner-builder will have the burden of proving that he did not Wild or improve far put- -
pose cf mleJ. .
❑1.m owrmr of Ne property,am eulusively connecting with licensed contractors ro .
same La dproject(Spy.o an owner
of property
Wilds
hereon,and -
cense Law dace nota apply to an owner of propel who Wilda or impto me Hereon,tib
who se Lace for such projau with ecantrarorta)licensed punuantNNe CantrecroYs
License Law.
❑tem cx nipt under Sm. .B&PCfor this memo
Owrur�I e,41, �4_ w _Dateec.y_;L 2ie4
WORS CCOI OMPENSATIONDECLARATION.
I hereby•?ren undern&r of perjury oro of the following ddcleeatione:
Iluve end will meinuina Cenifcam o/Comenuo self-insure for Wmkefe Comped- -
sation,as provided for by Section 3700 of the Labor Cade,for the pedoimana of the
walk for which this permit k issued.
❑i have and will maintain Woraces Compcmation Insurance.m miquired by Section
370Oof Ne LabofCode,for Nc performaae of Ne work for which this permit is issued.
My Worker ompemnion Ins anca gamer and Policy ..
Cartier: ERTIFICA OF XEMPTIONFRO
M RERS
COMPENSATION '
INSURANCE
(This cation neutron becomPlesed ifNepermis ie(Drone hundred tldlers(3100)
or lees.)
I employ
any Putin the mypaurfinovarm
ner of the work for which thin the W is its'Conshall
nom.Law any person iany manner so as to become subject m He Worked'Comped-
mGon Laws of California.eData
Applicant
NOTICE TO APPLICANT:e'slur making this Qnin provisions of th Labor od you should
become subject to Ne Workers Coons or tis eoshim of the Labor Code,you must
forthwith<ompty with such provisions or this permit shall be seemed revoked.
CONSTRUCTION LENDING AGENCY
C 0 Iherebyoffum Hettbeai.aconstration linnimgagemy to, performance of
r.a
the work for which this permit is issued(Sec.3097,Civ,C.)
Lenders Ne
a Lentis am
/s Addrtu
W 1 certify Nu 1 have it this application end stare and the above information is
Gtcorrect.l asome gree to comply with all city and county ordinances and slaws m1a ing m ,
Z building construction,and hereby mutual.representative.ofthis city to enmrupon Ne
U above-mentioned proper for inspection purposes.
W Ft' (We)agree to save,indemnify and kap homle.the City of Capon.against
Q t.) liabilities,judgments,costs and expenses which may in any way acme against said City.
in consequence of the grading of this permit.
(� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
f.J � SOURCERE.GULATIONS. ,.��kk O�a
'rgrWwe A�pQ�icanVContinuum 0� Data �/l/7a�ala(,/C•�(r .
HAZARDOUS MATERIALS DISCLOSURE
Will thompticam or future Wilding occupant store or handle haardons maurial Re-roofs
as defined by the Cupertino Municipal Cod,Chapter 9.12,and Ne Health end Safety
Code,SaOon 25532(a)+ Type of Roof
❑Yes Q"_
Will the applicant or future Wilding moupant use equipment or devices which All roofs shall be inspected prior to any roofing. material being
emit hazardous ab contaminants as defined by the Bay Area AU QaRty Management installed. If a roof is installed without first obtaming'an inspection
b' "pYes.i5k o� I agree to remove all new materials for inspection. Applicant
""oo' vemadthe Indications mammalsmquimmenamaker Chapter 6.95ofNoCati- Understands and will comply with all non point source regulations.
I..Health is Safety Code,Sections 25505,25533 and 25536.1 uMentand that if He
building does.currently have a Omni,that it is my responsibility to ratify the occepent
f Nc mluvuama,whia m t M amt pdatu iaauerm of a Cutin t of Occupancy.
.��7]�auN„I /���/. Signature of Applicant Date
OMrRf oron:W agent / -
AIl roof coverings to be Class"B"or better
OFFICE