00040074 rBUILDINICGIDIVISION
UPERTINO PE IT NO.
DIVISION PERMIT CONTRACTOR INFORMATION:ESS''..g' /// ysp� /J[J1`/ /�� 1,l{L� 11 'j�: 11 �IC�I +�cJ� „`' /.d~(•gQW/,sC W(Ate. SANITARY NO. APPLICATIONSUBMfITALDATE
^ t ,7p`AIJ , G..HOND
nNIC CONTROL#
INLER I // �a�, BULDING PERMIT INTI)
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LICENSED CONTRACTOR'S DECLARATION
zOa y=' 1 heresy emus Net 1 am licenud uasa proviaiona of Cha❑ter 9 0ommesing Job Description
S� u� wins S.tio.7f )ofDivisiw3ofl BusinessmW fessionsC mylittnse is
'G3G3 in full force and effect
Llttnm Cl eu Llc.#
3 a y Den Convenor
F u O RCHI'I iers DECLARATON
undefeated
my p0na eluTl be used u public records
KcLicensed PefemimW
OWNER-BUILDER DECLARATION
t Z a I thereby affirm that l sum exempt from the Contractor's License Law for the
M
following manna.(Section 7031.5,Business and Profemium Code:Any Cory a county
i which nquims a permit be concoct,elar,improve.demolish,or mpair any saucer. -Sy. Ft. Floor Area Valuation
prior m is ictrome,Wso requires the apphcae foroucb pemdno Messigoed autement �s al .�
Nal he is licensed".a.,to the provisions of the Comatose.Lt..Law(Chapter9 &
that
be
trecup: Sadon2000)ofbeenofie rhe Busiamaodm'Arr iCd.)or APN Number Occupancy Type
S he is essmpr m y aMti eras du p for Nc cul exemption.Any violation of 3z I_ L P Y YP
Section then veiny aced drIl fora permit mbjata the applicant to a rivil pemelry of O IJ
not mom dun five hundred dollen ftSW 1.
❑ I.a.awvanrNeproperry.amyempigeeawithw.gesmthehwlecamprvatian. Required Ins470
willdo Ne work,and the wuctun u not intended or offered for We(Sec.7044,Business
and Profnsiana Cede:The Cononton's Lime law dun tort apply to an ow.,of -
Property who builds or improves thereon,and who does such work himself Or R re,lb 9
his own employ.,,provided that such improvements lire not intended w offered for
covaco,hmwear.the buil0,bur len f,rr im,t sold wiid am s.b yld or improve
for the
rbuilda will have the burden of proving that he did not build m improve for pro-
pose of sole.).
❑I,a cenuoull the p or project
property,am exclusively contesting with Rcvuedonntssmn m
ccom Lai the project(Sac.o sm owner
of adrty whtiom Cede:)The Cs shaven,
U. T
whoIsco dm not applytoem owmer of property cotta builds ux improves thaeom,and !s/
who contracts for such projects w iN a eootruda(O I icemed puntum l0 0n Conbstoea
Lic<nm Law.
.❑1 am exempt uoda Sm. .B A P C for this won
Owner Date
WORKER'S COMPENSATION DECLARATION -
1 hereby sire under pchshy of perjury one of the following declarations:
1 have end will maintain a Certificau of Co.,to W6imare for WoranxCotnpen-
station.as provided For by Section 3200 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Wmkeea Comp mmum Imunsse,u n pAred by Section
37W ofdz Labor Cade,for the performance of me work for which this permit is issued.
My Wmkeh(rggpe sign 1pfW a carrier and Policy n vllnbp�. 71
Grtiee '�2YI'RS�S Policy No.: /Y/7_,._- —rsl`/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need trot be compleud i(Nepeemil is foronc huedreddollen($100)
or less.)
I certify that in the perforce.a me work for which this permit is issued.I shell
ml employ any person in any mummer so sum become subject to the Westerns'Compcn-
setion Laws of California.Dau
Applicant
NOTICE TO APPLICANT.If,after making Nis cirdrvate of Estmpuo..you should
Imcomt subject to the Worksea Compensation provisions of me labor Code.you mon
Forthwith comPly with Hoch provisions m this permit shall be dermad revoked.
CONSTRUCTION LENDING AGENCY
0 I lieteby afinn that Nem is a constmction Rodin,agency forth.pedomunc.of
me work For which this won..I is issued(Sac.3097.CO.C.)
h
F.. Leasee.Name
[(� > laodees Adde.
fry A I certify that 1 have read thus application and state that the above information is
96carnal.I spree, comply with WI city and county odtwta
iaes d rote laws relating to
Z building umanntion,and hereby ended.representation of mistily to tour upon the
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above-mentioned property for inspection purposes.
(We).grcs,he save,Indemnify and Resp harmless the City of Culertion-gains -
O O liabillUeS,judgments,tam and expenses which may ninny way same against mid City
^yes W in conscyw f the cru r of this pntnit.
[� :6 APPLIC TW )f I, r NILS 1}NDWILLCOMPLY WITH ALL NON80I
V SOURCI REGO 1 l�. 1 �1�ihM
Sig. fA cmn
JCovm
acr
1 HAZARDOUS MATERIMS DISCLOSURE
Wll theapplicamtor to.building ecoupen rose.,handle hamdous maurial Re-roofs
as defined by the Cupertino Mu
niIt h Code.Chaplet 9.12, nd athe Helm and Safe,
Codc,Section 85320)4 Type of Roof
Yn o ,
Will me
am
Offumn building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hewdous an contamimenuedellmed by Ne Bay Arca Ah Quality Menagemem installed. If a roof is installed without t-irst obtaining an inspection
""7c4
❑Yn 1 a ree to remove all new materials for inspection. Applicant
Ihave tadNth,mac".m,teriW,Rqui,ermenaunder Clos".6.95ofthe Gai- understands and will comply with all non point source regulations.
retia�-_c
8533 and 2553a.1 undersWd Net if the
is my usponsibiliry to notif tj.,se,
O9a011tt Of a CMiRC01 up
owner eters orieed.gt D Signature of Applicant Date
All roof coverings to be Class"B"or better
OFFICE