00050037 CITY OF CUPERTINO 'PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: _000 S OO 3 rl
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Z321 e4 � (' �/' �/ / � / 9� �� SANITARY NO. APPLICATION SUBMITTAL DAT]
OWNE MF J -7��OY//yr ��`�/�(" �f NIC CONTROL#
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ARCHITECT/E GINEER `�� #77Aw`
RQ ISULDING PERMIT INFO
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n LICENSED CONTRACTOR'S DECLARATION
r O y= 1 hereby awem that 1 am licensed under provisions of Chapter 9(Commencing Job Description
=tw with Salion T000)of Division3ofthe Busineesand Pmf"sions Code,and mylianu ie 7 I' �/J �/] /,�/y �////
on U in Nil force and effect -Te5litl1 Ve/VX SA l/(41 '/O"/✓/
o U License Lic.#
w 3 w Date Contractor /, .
u.O g
I ARCHITECTS DEC N em V
undersand my plans shall b u p
used ublic m'cmds
dei3O
o z Licensed Professional
-'N OWNER-BUI DER DECLARATION
h z a I hereby affirm that I am exempt from be Contractors License Law for the
❑ following maven.(Section 7031.5.Business and Professions Cade:Any city or county
n s m which legdros.permit an ca rmuc,alcor,improve,demdlah,IX refork any ormoom Sq. FL Floor Area Valuation
prior Ro is isauanm,dw rcquircs the apPlicem for wch permit to file•signed stament,
thatheislicencedpumlwtiodm Pmvisionsoftha Convacto/a I.i MIso(Chapter9
(<ammand.evdms«tian1t1001arlaviaian3arthebaalrc"adProreaiIXacox)IX Number OccupancyT
that he is exempt thereand the athe buil for the alleged exemption.Any v;olari.n of
APN/ /O YPe
Section 7031.5 by any applicant No.permit subjects the applicant to a civil penalty or
pt mom Nan live hundred dollars(5500).
I,mnw..of,hcproperty.ormyemPl"emwith wagma.ban wlacomprluwon. Required Inspections
willde Ne work,and the structure is rot invodedoroRend formle(Sec.1061.Bunncaa
and Profesvom Coda:The Contractor's License law docs of apply to M owner a
propsny who builds or improves thereon,and who does such work himself on through
his own employe",provided but such improvements arc not intended or offered for ..
sale.If,however.be Wilding or improvement is sold within one year arcompluion,the
owrcnW oder
Will have the Woman or proving wt he did nor Wad or improve for pm- '
POK a Wowrcr.). FI I tl A L E
como❑L u of ct property.un exclusively contracting with licensedommo 's m ,
mum a th proiem(Sec.7o/q owner
of and Rohso Wi Code:)lbe Conrtacto'e Cil
cense law docs not apply o an owner or property who Wilds or improv ed.ereon.W
whenseLacm(or roan prolecu with aconRratIX(s)licenaed purswmmthe Conmdors MAY 3 1 2001
License law.
❑hem"empt ender ga. .BAPCfar Nis rtawn
°w"" Data BUILDING
WORKER'S COMPENSATION DECLARATION
1 thereby arms under peralty of Perjury one of the following declarmiom:
I I hove and will mainwn•CmificartofComcm to Klf insert fIX Worker.Carnpem
cation,a.provided for by Section 3100 of be Labor Code.for the pedmnarr<of the -
orwhich this permit is issued.
woll have and will maintain Workers Compensation Insurance,u required by Section
3700 of the IaWr Code,for the performance of she work for which Nis permit is iswed.
My acamer not Policy
numhvT/Z 33
Cmncn art �f//�S/ PolicyIW, S
CERTIFICATE OF P.KEMFTION FROM WORKERS'
COMPENSATION INSURANCE
(This acclimated no,becomplemd if Ne permit in foroo hundred dollars(5100)
or 1"a.)
I minify that in the performance of Ne wart for which this permit is issued.]shall
not employ any Pelson in any manor w as to become subject to the,Worker.Compere
'section law.of C ilifomia.Dale
Applicant
NOTICE TO APPLICANT:If,after making this Cemfi"m of Exemption,you should
became subject in the Workers Compeuallon provisions of be Libor Cade.you mute
foraAwith comply with such provisions or this panni,anal]b deemed mvakcd.
CONSTRUCTION LENDING AGENCY
Q I hereby arms that on.iso c...troN.nmuding agency fo"he prrfaa t.f
z the wok for which this gamut is issued(Sec.3(197.Co.C.)
N
Landers Name
ori 7 Leodre.Addreas
L61 1 certify Net 1 have read this application and sate but be above information is
G correct.I agmc to comply with all city and county ordinances and num laws relating to
Z building construction.and bemby,audience rcpreKnwiv"of this city to enter upon be
(.) abnvementioned property for inspection purposes.
(We)agree to evve.i"dcmniry and keep herml"s be City of Colombo,
Q C.) Iiahilumi,judgroms,cot,add expanses which may in any way accrue against mid City _
>. (.] in consequence he rooting of Nu permit. l�s Q`L�
[.w fPa APPLICANT i )I (STANDS ANI)WII.LCOMPI.YWITHAI.I.NON.POINI' d� ♦ (✓
SOURCE RE:R I
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Siat
gnure of cant/Con romm Dare
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant"None biking simulated store or lanNe harard.us material Re-roofs
as defined by the C.PLIY.a Municipal Code.Chapter 9.12.and Nc Health and Safety Type of Roof
Code,Section 25532(.)7 YP
❑Yes
Will the eDDlicant or future Wilding acupmt use equipmem or dcvias wM1icM1 All roofs shall be inspected prior to any roofing material being.
cashhaa. issrcommi Blood by be Bay Area AnQualityM.mgement installed. If a roof is Installed without first obtaining an inspection
Dianna,' I a ree t r ova all new materials for inspection. Applicant
❑Yes
I have mailthe aaardolr moratoria requirement,ander Chapter 6.95 of the Cali un erect and will comply with all non point source regulations.
form Vaal ars code.Savour 25505,u533 and 25531.L u d .d thu if Ne
building n dy have a Ronan,most it is my responsibility to alify Ne occupanl 6J
of be sryahien mus,W m"prim in amerce as CmiO<are or occupancy.
—Z — Signatur f Applicant Date
Owns Or n agent Dam
All roof coverings to be Class"B"or better
OFFICE