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00050056Lata a V., IVa Tia\a al\V n� ' BUILDING DIVISION PERMIT CONTRACTOR'I'NFOR_MATION: W�5©��/„ BuntiNcnuDREss: �� of, I �I) 'n �,. UB / /5�� U fhb J SANITARY NO. APPLICATIONSUOTTAL DAT OWI Ia'SNAME: /_` d QQ'' C �^ /�~ CO DAna, [[(,�IvcJ` 1 NIC CONTROLN PH(N.'.: SO1T ❑ Gti ��A.a C40,4 ARCHITECT'?NCINIiFik HOLDING PERMIT INFO LICENSED CONTRACTOR'S DECLARATION I hereby affirm that 1 sm licensed rade, provisions of Chapter 9 (commencing with Section 9000) of Division 3 of tW Business and Prefmiow Code, and my license is in Nil force and eRecy. 'J'/ License Clesa C —JF LiaCHMN T`n'DElw ARaludlb used DECLARATI N 1 undersand my plans shall W used as public records Licamd Professmed OWNER -BUILDER DEC'IARATION I harcby .Kum that 1 am eacmpr from the Contracmh License law, for IN following mason. (Section 7031.5, Business ad Pro&cions Code: Any city, or eouny, which rcquima a permit in construct, alar, improve, demolish, Or mpair any shuchae prior to its kmance. also requires the appficam fwsuch poorest to file. signed statement than he is licensed pursuant to We provisions of the Conummors Licevu law (Chi 9 (commencing with Sermon ]000) of Division 3 of da Business and Pmfeuions Cod.) of that he is mane,, thacfrom ad the, basis for fie alleged exemption. Any violist of Section 7031.5 by any applicants for is famous sabymts she applicant toe civil pointy of or more than five hundred dollars Mail). Laaownw of Wepropen,mmyempi'mutoith wa8u asthair onto compo wdl do We work. and dve some 1. 1. and imndd or off,: L9 We(See.]0a4,B ss and Professions Code: The Cennawur'a License law does nor apply 1r an ow property who builds or improves theeem,, and won does such work himself or through his own employees, provided that such improvements sue as intended a offered for ale. If, however, We building Or improvement is sold within one yeas of emopt don, the owner -Wilder will have the bunion of proving that he did net Wild w improve forw p - pose a We.). ❑ I. as owner of the property. am asdusively connecting with licensed contractors to construct the project (Sm. 7041, Business and Professions Code) The Con mcme. Li. cense Law dors rot apply m an ownw of property who Wilda or improvas tha<em W who contracts for such mil with iscontracmdsl licensed p rnuam in the Comraclofs Lima. Law. 1 am aemps muse, See. . B d P C for this,aeon Owner Data WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty, of perjury one of the following dada atiou: ❑ 1 have and will maintain a Certificate of Consent o self -insure for Workers Comped. .tion. as provided for by Section 5700 of de, tabor Code, for the parformutce of the work for which Wis permit is issued. ❑ 1 have and will maintain Workers Compensation Insurance, as requied by Section 3900of five Labor Code, for the, perfomwae ofilm work for which this permit is ismad. My Wo s Compenset'q by w antl Policy ny ase: Caenar�• lvf Iq ryv_unnceFasn Policy No. y� �4i sR CERTMCATE II PfION MOM WORKERS' COMPENSATION INSURANCE (Thi. acdnnnrol netWcompleed ifthe permit iafw one huedr.ddalan 15100) or less.) I minify thin in the padomunce of the work for which thispmout is issued, I shall not employ any person in any manner w as to hewme subject to the Wotfea' Co rater - sation laws of California. Date Applicant NOTICE TO APPLICANT: IL afar making this Cer iOcine of Exemption, you should become subject to the Worked. Compensation provisions of the Iabw Code, you tont forthwith comply with such provisions or this permit hall W destined mvokd. CONSTRUCTION LENDING AGENCY 1 hereby elf ten the thio is sued (S . 30 7, Civg agency fonhe perfmmance a We work for which this pcmdt is issued (Sec. J09], Civ, CJ Leaders Address I certify that 1 have sad this application and ewe that the above information is torten. I agree to comply with dl city and county wdwnces and sora laws rohting to building construction, and hereby awhonse ropreanwives of this city to enter upon the above-memiond property for inspection purposes. (We) agree to ave, indemnify and keep hasmless the City of Cup.nino.gaunt liabilities, judgments, costs end e.penas which may in any way amme.galnat said City in con. t,mce of the granting of this permil. AVPLICAN'tON[IERSTANDS ANTI %. COMPI.I' WITH ALL NON -POINT S(IURC1. RIiGUI ON' J _.00 0 Signst p1lMcenVCmm�cmr Dar HAZARDOUS MATERIALS DISCLOSURE Will IN, applicant or future Wilding occupant stun or ladle haaandous material as def nod by the Cupertino Municipal Civic. Chapter 9.12, rest dor Health end Safety Code. Senion 25532(.)^ ❑Yes ON. 'Will the applicant Of future building Occupant use equipment or devices which emit hair t.us air comamimna as defind by We Bay Aro. Ah Quality Metegene,nt Disvict] ❑Yes ❑No 1 have road Or hazardous materials roquimmenn under chager 6.95 of the cab- fornia Huhh & Safety Code, Sccdom 25505. 25533 ed 2553x.1 undersuM that if Oa Wilding does nee currently have a Roam, than it is my respomibiliry a ready the wcupmt of the "mrcmenu which must be me paw to issuance of r Certificate of Occupancy, Owner or auJronzd agent Date Job Description 8 (r 1 x-(- ,. ,cam Sq. Ft. Floor Area I Re -roofs Type of Roof All roofs shall be inspected prior to any roofing material being installed. If a roof is Installed without first obtaining an inspection I agree to remove all new materials for inspection. Applicant understands and will comply with all non point source regulations. Signature of Applicant OFFICE All roof Date to be Class "B" or better