00030163 CITY OF CUPERTINO PERMRNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS:
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40 ARCHITECT/ENGINEERZ.
/ BULUING I'IiRFtIT INFO
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F.. LICENSED CONTRACTOR'S DECLARATION
OO z N, I bn ls,affirm dna,I am licamed under provisions of chapter 9(commencing Job Description
t-_E; with Sa,ion 7000)cf Division 3oftheBminces and Ptnfemmi Code,mond my license is
en mfullfors wad carp_/O / 1-ic.N 72—,
r',
O w U license CI ( f
3 u N Data
in ARCH Iseme DEC ATION
d ¢9 I undenuad my Plashall W sero u public dcotds
a a c Lic,m Profeasiorel
w R y OWNER-BUILDER DECLARATION
1 hereby aft Nal i am exempt from the Controversies License law fel the
F G following monad.(Section-ro31 S.
Business WPmf loin Cede:My city w county
C en
which requGcs a permit m construct,Blur,improve,demolish,or repair any mucture
c.s Sy. FL Floor Area Valuation
protein its issuance.slsroequirts the applicam for such pemdt w rile a aigMd suramin [w-o
duo he is cilig ees punumm w Ne proviaons of the Conea,ole Lianaz law(Cluper 9 8�Q-
(eommereixemims«monand Be
1�11... APN Number Occupancy Type
Nal he is exempt dentition applicant
li and the.pais per the cts the exemption.Any it F violation of ^ 1 �� 61/ Yp
Semon e Box, by any applicant fa x 00). subjects the appliceno m e civil pcnilty of !s Jl
w1 dnoc Nen five huadrd dollen(53001.
Lan wlk..tha se =isy mien moffmgasmthc(Smecrmpeuawn Required Inspections
ad odthe work,anddo he Common's
Landofanapply.1Ono,Business
and ery who
Code:The ews cover's Liame Law docs not apply to if mwrcr gh
his o ny who build,or improvca thereon,sad who does such woter himselforthoroughor
his awn employed,provided w,pro improvements art not imeMN a oifcrtd for
xde.If.
aiddo wido buil dingorimpowement istold within non year imponle for ion
owmr-Widtt will have 1M.u,den of proving that he did not Wild m impmve for pm-
pou of sowne
❑h construct owner Lf the property,,a ea,u mal prolamines oidsCod lappa Contaers .
,no.Lathe prone,(Seca 7M8,owner
of ad property
whbut&oruTM Cwuersore nd
censelawdoes nmchply,eee ownerofpropcns who.mirexor al to the
Nermn,sed
who contracts For such po)ecu wiN•conwcmds)IRcnaed Formal to the Crnuaptora
License law.
1 em exempt under Sm. .B&P C for this twnn
Owner Dem
WORKER'S COMPENSATION DECLARATION
1 hemhy affirm under penalty of pe Jury ore of the following decluaticns:
1 have and will coalman a Canteen,of Consent to alf-insum for Welkces Cooper.
ration,as provided for by Section 3700 of the Lmor Code,for Am'do..of Ile
Jworkfof which this pent is issued.
have and!will maintainWorkers CLmpcnauon Insurance,es rtquird by Section
g]O�of the labor Code,fa Ne prlomunce of the work far wlich this permit is ianud.
My Worker m uuL seine c 'nand Policy minor : ^B
Carrier: Policy No.: d
CLRTIFT�F`uON FROM WORKERS'
COMPENSATION INSURANCE
(This sectio need n,h comPletdifthe petit in forme hundred dollen(SIM)
or Icu.)
1 ratify that in the performance of the work for which this permit is issued.1 that
am mildly any person to any an.so u w(become subject to the Woherncomped-
.nonLaws ofCalifornia.Dam
Applicant
NOTICE TO APPLICAM':If,after malting this CeniBeate,of Exemption,you should
become subject to the Welker,Compen mmis provisions of the Label Cade,yin must
forthwith comply with such provisions m this pcti,shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
Q 0 Ihereby elftthu them is a construction leading agency for tie pmor mce of
Z Ne work for which Nis patina,is island(Sn.3097,Co.C.)
Lenders Name
y' >_ Lenders Address
{,F,t I certify the,1 have red This application and tine hal Ibe above information is
IL Z cunagree,
correct.I mgto comply with tll city acountyccountycontinentalycontinentaluncea sadin
mate lens t miming to
U Z buildi.mati edproedd hemhyeumouserposes ivd often,oily menuruprn the
U O abLvctotirnd,property for inspection roup ha.
k. U (we)mgrs,r save,indemnify andhoh ayi m theymofx.,Fumeoid it
U in
be .do,dpense wM1ichnreYin anY waY varve aeons,said City
} 4- in con TCAscr of ted,granting of this pout.
[•+ G AI'I'LICANT ONUIiRSIANDS AND WILL COMPLY WITII ALI,NON-PoINT
U z SOURCE R RGGL4
' j_
Signmucul'Applicam,cmdractm Data f®v
HAZARDOUS MAT La lS DISCLOSURE
Will the applicant or fumrt Wilding occupant,ort or habile Woudour mamma Re-roofs
as defined by the Coalition Municipal Code,Chapter 9.12.and the Health end Safety Type of Root
Code,section 255320)7 ��- ///''' yP
[]Yetf�5�'L
Will the applicant or home Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being.
mio hnallom airconumintu as defnd by tic Bay Arca Ab Quality Management installed. If a roof is installed without first obtaining an inspection
°i°'
❑Yes /KN. I a ree to remove all new materials for inspection. Applicant
Iha rod the h.rardrm mamma,momminu s under hapter 6.95 of the Col. un erstands and will comply with all non point source regulations.
rani,Health&Safety Code.Satimu 15505.25533 and 2553e.I undersand Thu if the
Wilding does�paeopq rwrentl1yt�hauvse,�aelenam,thm'n is my respomibility to notify the ompml
of theF/7 /sC met pow w' arca ofeCmibcem of tYcupeay.
F/7
,(" 3—Z7l—pfJ Si nature of Applicant Date
Owne thodzed agent Data
All roof coverings to be Class"B"or better
OFFICE