00010022 CITY OF CUPERTINO n PEItMITNO.g'� h .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: VOO[,{. OO 11 ,11 .
BUILDINUADGAESS:
r SANITARY NO. APPLICATION SUBMITTAL DATI
WNF :NAME: , 1..h _ �'" n1 �'/ 'r �JJ _G�., S„i L
Ga IO g1 /62 8 7 (1 5..,. vim., /1/17-• I:JIVbt NA, CONTROI.�0
HONE: L ��/,�Ci ❑
ARCHIT'ECr?ENGINCER BULDING PERMIT INFO
LICENSED CONTRACTORS DECLARATION
G 1 hereby affirm dust 1 who liccmed under rovisiom of ChapNr 9(mnvancie8 Job Description
p:(:w with
-� withSwum] [of
CDivision 3of NBusiness ad Professions Code.aM my license is
foe ninN]IrtI<IT
05
Lianx C1aa Lic.M q 9
u-o.0..5 Dne1� Convenor O Coe
R ,/Y ) ^ A
[_u 0.5 ARCHpECTS DECLARATO 1" ��I-/
y— 1 mdenurd my plan"I farmed u public meows
i O Licensed Professional
OWNER-BUILDER DECLARATION
C z¢ 1 horrby aRrea that I sm exempt from Ne Convectors Licmu law for the
E F G followers..(Semon]031.5.Buxircss aM Pwdlf rum Cade:Any city a county
mrei C which reponse a permit facmulrvn,dur,improve,demolish,m repair any nmcame
pnonunni,kmance,9.mean.,WapPliantformchpermit tofil...igmedsuumem Sq. Ft. Floor Area /A Valual n
that he is licensed pwemnuo the provisions of the Contractors License Law(Chapter 9 DOp.
that
he is exempt
du cdo rn and t f basis for theal a ed!euaMR,Any mCode)on APN Number Occupancy Type
Out he is eumpr therefrom and du burs for the alleged!exemption.Any l poscaon of
5erdon,703 1 dam five
eery red applicant for•permit subjects Ne applicant to a civil puWry of
not more,Nen firs nmedmd mnax(ssoo).
❑1, ewnernrmepropeny.nrmyemvlayee.wmw.gexumeirrolerompena,ean. Required Inspections -
willdothe work,and theaructore is not intended oroReo-A for sale(Sec.7014.Business
and Profeaons Code:The Contractor.Li..Law dos era apply to an owns of
property who Wilds or improve thereon,and who does such winds himself or NrmUr ,
his own employers,provided then such improvemenu art me inuMed or offered for ,
We,If,however,the Wilding or improvement is sola within oa yeacrof mmpletion,the
poser-Wer ildwill have the banks.of moving that he did not Wild or improve for Pur-
of sale.
h m ow of Ne property,a s exclusively commcdng wish toward contractors to
muo c,the pmjrcr(Se.7044.Basin.and Prefe siona Code:)This Contractor's Li-
Crew
i-c ew law does rot appy to an owner.I propenry who W iia or improve.thrrton,aM �.1
who comms for such projects with a Contrumrfs)licensed punemuo Ne Contracmrs
License Law.
m O
I aexempt under Sm. ,BkPCfor this moron Q
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 thereby affirm under Family,of perjury one of the u
following declasatio :
C]l have and will maintain a Certificac of Consent to uU-insumforWmkersComper-
Wim.as provided for by Semon 37W of Ne Labor Code,for the performance of the
wok for which Nix permit is it ow.
❑1 have sued will maintain Waters Compensation Imumme,as mTuimd by Section
3700 oo/Ne labor PCLode,fear/N teerrffocrmutow of do wort foe which Nis permit is bond.
MyW scorn upio rFl"moi/marts Yolicyp fgkt�ry.�y2 T2
Carne Polic No bl�/L./
�CERT12ATE OF EKE MON FROM WORKERS'
COMPENSATION INSURANCE
(This rernm nerd nm becmnpletedifthc permit is faoa hundred!"Was ujah
or Ica.)
1 certify that in she performance of the work for which this pemue is iuued,I shall
WE employ my French in eery manor in u m firm.sun.N the Wmi,eri Compen-
sation Laws of Califinum Due
Applicant
NOTICE TO APPLICANT:If.afar making this Cenificau of Exemption,you should
becorm suhjat to Ne Wor r x Compensation provisions of the Labor Code,you most ,
f.Mwilh comply wit such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
O Q I hrreby affirm Net there is a construction lending agency for the pMemmaa of
► y thewinds for which Nis pC.it is issued(Sec.309].Civ.C.)
(~ Lenz,Name
(� > tondo's Address
k) I certify that I have«W aids application and rude that the above information is
A. z Correct.I agree to comply with all city aM county ordinances and sue laws relating an
V Wilding comtruction,tad berrbymmunice mpreaonue
tivofthiscidy former upon the
O
above-mentioned propmy for inspection purposes.
fst E.. (We)agree to save.indemnity and kap harmless the City of Cupertino against
O V liabilities,judgments,craft and expenses which may in any way accrue against aid City
y W in Concrete.of the funding of this pe
[� APPLICANT UNDERSI'ANII' ND L COMPLY WE I'H ALL NON-P(INT
V z SOURCIi REGU S -
- y-5-inti .
Signature a. eomnct Dae y�6% DD
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicamorfume Wilding aepsnt store.,haMle haertbus maerial -rOOfS
as defied by the Cupertino Municipal Code.Chapter 9.12,am!she Health and Safety
Code.Section 0532m)] Type of Roof
C]Yes �o
Will da applicant or future Wilding acmpmn tie equipmem or devices which All roofs shall be inspected prior to any roofing material being
emit haardous ab conommmus u defined by the,Bay Are Air QWiry,Management installed. If a roof is installed without first obtaining an inspection
District?
❑Yea a1c-� I agree to remove all new materials for inspection. Applicant
Ihave usual theliamrdm,maenal.romirtmcnumull Chaffer 6.95ofme,Cai- understands and will comply with all non point source regulations.
fomu NeaIN A Saay Code.Savmu 23 .23533 and 25534.I mdvaend don 1f the
Wildingdocxwa ly won tis mY rtspomibilirytonmify Nr.Pans
of the u' a est he p,i3 ^���a Corr eau of Occupay.
_ Signature of Applicant Date
Owner thin-M agem Date
All roof coverings to be Class"B"or better
OFFICE