00040038 CITY OF
CONTRACTOR INFORMATION: PERMITNO.
PERMIT 0004/00319
BUILDING ADDRPSS:
a' a r/4/0 '511A1�S'LY/1//JO:rsf RW)P�P I Ss�tf', r/V C- SANITARYNO.- APPLICATIONSUBMnTALDATE
OWNER'S NAME: 'V (.7�f1fF . C '� "T(l'��rLT'°��
8 cv li L ,x339 /' s�EcT d'e� �/8 Np y�8•Z a
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ARCHITECfICNGINEER �� �o SArI.J0SE, &4 9J /� RULDING PERMIT INFO
f—?i LICENSED CONTRACT'OR'S DECLARATION
ZO 2 I hereby athmr that 1 am licensed under provisions of Chapter 9(commencing - Job Description
<v3�u with Secti..7").f Division30fthe Bn31ncss"ffnsions ?gel
$ in full force and effort C
to m i h Lbm Clsss, Lic.M
r Dme Cwuacta tYJy�ll f/t/11(k(�D ��•` ���
a•a O ARCHITBCPS DECLARATION (U!f Ibk1(1 II ITV//t/'lUfll`7\\\I/\I
� Q� Iundmtand my Plate alWlBausedm public records
so ne
Licwsed Pwfesslonal
c 6!2� OWNER-BUILDER DECLARATION
t_2< I hereby affirm But 1 and exempt from the Contractors License Law for the C//�•,
I H o following recon.(Section 7031.5,Busirsem ad Professiaw Code:My city,a county
which reaubea A permit b camfeuck alter,improve.demolish.or repair coy svunue
3 prinrtoitsmonsoon.sho"oi..theapplicantfaswhpemtitwft...ignduatereenr Sq. Ft. Floor Area Valuation o
dist he is licensed punuantto the provisions of the Conrrsca'.License Law(Chaga 9 r�� OL)
fcommosto.g with Section 7")of Division 3 of the Business and ferf.aiom Centel ace .p N Number Occu T
that lis is exempt therefromd erear Basis for the alleged...Minn.Any violation of Pane Y YPe
Section 7031.5 by any Applicant(a a pemJt subjects rhe applicant to a civil puulty of O e j
not more Nen(e hundred dollar(6500).
C1L.,owmofthepropany,m myemployeeswithwagawtheirsoicwmparnaafim. Required Inspections
will do the work,ad thcavuctures is not intended or ofteml for We(Sm.7010,Business
And Professions Cade:no Contractors License law does trot apply to an owner a
propene who builds or improves thereon,And who dao molt work himself ar through
his own employ.,,provided thm each improvements see not intended or idpi for
sale.If.however,the building or improvement is cold within one year of completion,Ban
owveobuilder will have fee burden of proving that he did not build in improve for poo-
1,
construct owner of propane, reclusively confessions with licensed wnfrsswn Ne project
(Sec.]oOG,Business and professions Cd.:)The Conuaa'c U.
come law dors not apply to tsish a of property who builds or improve thereat,rod
w
who enantsfor such projects wish eontrWa(s)licensed pursuant to the Conuactofe
License law.
❑lure exempr .underSec. - .Bh PC fa Nis rtssan A
Ownu De -
WORKERS COMPENSATION DECLARATIOO N
Rm
1 hereby arundernder penalty of perjury one of his following decluatiomu:
lies
wins.
ad will feet by Section
37M of the Lisair WdemureforWorker'sCompere-
weekf a provided for by Section 3]00 of the Labor Cade,for the pahomunce of the O
week(or which Nis pcmtiis issued. _
❑I lute And will maintain Workers Coce ofthn,w Wuawwhi h requited by Section
My%ithefabm Cdaionthe pancecarrie .the work for
numbrnthis permit is iuucd.
My Worker's Compensation Insurance cornier and Polley number are:
Cartier: Policy FROM
CERTfPICATE OF PS rION I N FROM WORKPAS' ^ /
CO mem,) TION INSURANCE /
(Thio scninn red not becmnPlmedoldie,pcmdt is foronc hudred dollars(5100) ,� O
ar fres.) e
I Amory But in the partmmmer of the work for which this th emh r issued,l shill
not employ any parson incoy manner w as to become subject w the Waren'Compere _
Applicnt of California.aData
Applicant
NUI3CElU APP LICANT:re after Compensation
this Cmsums of of Labor iodyou nshimid
must ,e
hecomc subjecttoit Wohcro Coons or
is provisions of the Labor Code,. reser
forthwith comply with such provisions m Nis pounds shell bu decreed rooked.
CONM C`f1ON LENDING AGENCY
0 Q Ihereby affirm Bw there is A chrorudw lending agency fee the performance of
Z the work for which this permit u issued(Sec.3097,Co.C.)
E. Udee.Name
> Under',Address
W 0 I canny,wt 1 have red trout applicnien and sum that the,above information is
SS correct.I.gree to comply with all city ad county odinurcea Aviation laws relating to
z buildingm.maction,and hereby minimize reprowutivem ofthis city to enter upon the
V .bow-hof ioncd propeny for inspection purposes.
Pk Fy (We)agree native,indemnify and keit,harmless the City of Cs,ni.against
f, Iiabilios,judgmenu,maxi expenses which may in any way accrueegainsl mid City
fro in consequence ofthe granting of this,writ.
P+ APPLICAN'PUNDERSTA RAND WILLCUMPLY WITHALLNUNYOIN'f
V z SOURCF.1 IIA' . N-
Sr6 Dau (] y 2�aa z ♦ 9,
HAZARDOUS MATERIALS DISCLOSURE
Will Be applicant ce force building comport store or hanLle buadous material Re-roofs
in defined by the Cupertino Municipal Cde,Chapter 9.12.And the Hetlde And Safety '
Cede.Section 25532(a)] � Type of Roof
Cl Yes ❑No
Will the applicant or forum building occupant use equipmem or dcvoo,which All roofs shall be inspected prior to any roofing material being
cdt" douheraa ab w contaminants defined by the Bay Area Ab Quality Man'tramt installed. If a roof is installed without first obtaining an inspection
"""oy.. cx-� I aggree to remove all new materials for inspection. Applicant
I have reed the Bamdwamaterial,rtgairemenu under Chapter 6.95 of the Cali- un9—A7
a d will comply with all non point source regulations.
forme Health&Safety Code.Sonicate 25505,25533 and 25530.I understand this if the
building does ads curer yy have A tenant.tem it is my responsibility to amity the occupant
of them M1 t ern prior w umwwc of a Cmiti to of w pancy.
.,,r1.V�K a(1 0 re of Applicant Date
Owne r A en Dem ��--
All roof coverings to be Class`B"or better
OFFICE