00040138 CITY OF CUPERTINO - PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION, 000�01,S$
BUILDINGADDRESS'' C _ nd1x1 bo&d �l SANITARY NO, PLICATIONSUBMFLDATE
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ARCHITECTIENGINEER 1 1 /Amf1V' ��� BULDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
o z c 1 hereby affirmor dl am licensed udc povisimss of Clu rte 9 fconraI Job Description
r:t:w wish Sation]000)ofDivision3ofthe Busiees�s3aM/�fm•ions CC° .°ndmylianseis
�zd< in Nil tome 3 Lie.N TI--�I(oV`
uvi
0,U i DaerT��Co..^,('"ryAlbIlylind Filter,
F=O gARCHITF,CrS DECLARATION
1 avdeereml my plat sball he used in Whh,rtcads L /,
wap II VD�
Licensed Professional y�
OWNER BU rpt from
DECLARATION
C Z a I W esso aR.m that 1 ern exempt from Ne Convectors s:My c Law for the
E t G follou. whock,ng tures a Permit
O ]ommu t,war mpsured Pm(ion Costs:MY city s county
„rilr a req°i....pe^^h m norssauct.inter,improve,dem.Erh..r,mir am ammwe Sq. Ft. Floor Area Valuation
prior m s licensed
a,also regoiae the applicant roe such permit mice a Law(meamat
that(cmheisflamed rection mthe.f Divitimofthe C.ntsanew, License Law(Chapter
centres umui, Section shred)the
Iisui for the CeW exu andca.Any
APN Number Occupancy Type
wt he is exempt theerrom w dm beie for the almged exempri.n.Aran vbwtion.r O i _ O P Y YP
sa_
Section]0313 by my°pplieeat fa a permit subjects the applicant to a civil pemlry of
t mor then eve hmdsed dollar(3588).
❑kers norm,of the pr.peny,or my employees with wag.etheir sole c.mpcmadou. Re fired Inspections
will do the work,andshe structure is not intendedoroRemA formic(Sm.7044,Famous
and!Profession Cmx:The C...e is Lics.ve law dour not apply m an memor of
property who Wilda or impemea dureon,ad who dura mch work himself or though
his own emp)oyees,Provided dor such imProveranss am ret included a offered for
We.If,however.die Welding or impmvcment is sold within rte year of ampWion,dre
wneoWilder will have de W.den a proving doss he did not Wild or improve for Wr-
pose of sale.).
ri I,u owner of the property,am exclusively contracting with licensed conuamors in
construct the project(Sm.7044,Business and Professions C°dep The Contractors U.
cern Law docs not apply..an own.of property avW Wilds or improve Increase.and
who contracts for such prolan with a mntractmW limited punurs ON the Convecsore
Lt..Lew.
1 em exempt oder Sa. .B&P C far this reason l
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 h.eby arm under perm,or perjury me of rhe following dMareiam:
❑Ihave and will rn°inrnaCeniecaseofCormuo self-insumfor Workc'sCompere O
rasion.m provided for by Such.3]00 of the Lebo,Code,roe she MK..nce of the
work fol. Ic this permit is issued. v
❑1 have if i in or�(�s nseto.Irurence,ss required by Smith.
3]OOof (utit'eofsW work for which Nis it is issued.
My wore, .and Pol' um
Cartier.�(�Policy N .
CERTIFICATEOFEXEMPfION FRO WORKERS'
COMPENSATION INSURANCE
Intl section need nm be,ompleud ifthe pemut is furore hundred"Ins(SI00)
or los.)
I certify that in the Prof.of the work be which this permit is Wood,l shall
not employ any person in any manner.o as to become subject o the Wurkea'Compen-
salion Laws of Caliroria.Data
Applicant
NODCETO APPLICAM':If,afar making this cure fiat of Exemption,you should
become subject to the Workers Compemamion provisions of the Labe Cede.you mum
Forthwith comply with such provisions or this permit shall W disclosed revoked.
CONSTRUCTION LENDING AGENCY
Q O I Wmby affirm sham them is a construction lending agency for she perfmmvee or
Z 1W work for which Nis peanut is Ismed(Ser.3097.Civ.C.)
4 ladles Name
a > larder's Address
I certify thm I have reed this application and erase that the above infotsmtion is
Q. Qcorrect.I agree comply with all city aro county.rdimnces Audistatelaws aiming so
7 Z building construction.and hereby aushoria.epresmmives or this city to enter upon the
U Q abovemeriomd property Ta inpecume surpnea.
W (~ (We)agree to wave,indemnify end keep Outmlrss the City or Cupertino agaimt
Q r) liabienjes•ledgnents,cents and expenses which may in any way°ccnaagainst said City
�.r W in conaquence,of the grning of this permit.
rt•+ 0. AI'PLI' N'I'UNIIPItg'1'ANTS AND WI LL COMPLY WI'1'11 ALL NON-INA
U Z SU Cli EGUTATIONS. —';?/ —/91 q�_
riaumof ApphanUContnctor P/ Dame,
HAZARDOUS MATERIALS DISCLOSURE
Will do,applicant or future Wilding occupant more or handle hazardous mammal Re-roofs
as defined by the Cupertino Municipal Cdc,Chapter 9.12,and the Health and Safety Type of Roof
Code.Section 2153x.)' YP
❑Yes ON.
Will the applicant at future Wilding occupant use muipmem or devices which All roofs shall be inspected prior to any roofing, material being
emit hazard°us at,mluxrinentsa,deRnd by the Bay Area Air Quality Manm
ageent' installed. If a roof is Installed without first obtaining an inspection
D19Q1t,? I a ree to remove I new materials for inspection. Applicant
❑Ym ❑No
I have read the ram
Ismaticm,ro al,requirements model Chapter 695°f to Cale—
brands Ilalth Of Safety Code.Sections 25505,25533 end 25534.1 udersand that if the ` //��
huilding auveryheive.tmem, Yresponibilirymnniry the acupans / V
of u which m rep_be rocs co rss a 'fi Occu_c
/'�^� gnature of pplicant Date
Ow or authonzed ant Uate
All roof coverings to be Class"B"or better
OFFICE