00040179 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTORINFORMATIONv
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RCHITECf/ENGINEER / BULDI,NG PERMIT INFO
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j7VS04,— ?77-3 2.2 U6
Hu LICli!SSED CONTRACIOR'S DECLARATION y
z o H l hereby swan that that 1 am
m licensed under provisions of Chapter 9(comenting I• Job Description
rt"9' with Scion]000)of Division 3 of the Business uM Pmfeuions Cade.and my license is r
sSri a in full force sena eKcct. a g1 u f1 r /,
O on O uc....clan sec.« N Gra Zee i-ej U.41 IdrV C•'r a. '�— `•YO g" Ll
uo 3 u Data Co.wc,or a
Og ARCHITECrS DECLARATION Wit
hL 4` vk-(, (,�yal9
v� $ 1 understand my plans shall be used u public mwNs
a a e uce tins Professional ,A (( D
OWNER.BMIYU DECLAdra ARATION •Z. RVA QL�-f Gi4i�/• /.yJ lT� 0 4—44-4, /14,0W 4 «
C Z< 1 hereby aRrm that 1 Wirt.vamp,from the ConttactoYs License law for the
F❑ following rcawn.(section 703 1.5,Business and Professions Cede:Any city or wumy
u.3 m whmh occludes.panni,to cora uc,,altar,improve,demolish,or rtpair any a.. Sq. Ft. Floor Area Valuation
prior to its Ixumnce,aka rc9uires the apPRunt foramh permit to file•signed shncmem
that be is licemed punwnt m Ne Provisions of the Conmcmre Lieense law fCTaptt 9
that he
ixem it onefim ]0001 of Diviaion3 the
exemption
Any
Cade) A� umbe� Oce ane T
Nat be is enemy, Ser fian and the basis for of alleged armp,iom Any vlolaao of GCL/J Y Y
Section]0)1.5 by any.,hrant fours permit the applicant to a civil penal of �+
pt more Nen five hundred dollars(S500).
1.at owner arthe property,m my.ntployeea with w.gm u dteir ante eompe Required Inspections
will neorisewmk,ands: no corms noti Livens, wdofmsalt(Ser.]014.Bnera
and eu,,Moro Cosec:in oyes thcwf.License Law does nm apply m an owner of �
property who oyies or improv,march,and who d«a such wove himself of thringh
far
his own ounevc ti,provided Wt wove mentis sold would-
u.not intended m offend fm
sele.If,however,ted buil ding serimp f moven li WildwiadnoneildorI prove four the
neral ilder will have the C,Nrn of moving that W did not Wild m improve fm For-
pose
of
selene.
co a u owner of the property,,Business s turd conusciing with:)TIM Ccnnvacmrs m ilia.L eal'71/
comwet u promo(Ser.004q werofant property
v W ons;Wild,
Codes TW Cs therim's nd
M.Law does rot apply a ts owner of properry who Wilds m imma.m Corton.and
who contracts for With mojeem with a connotations)licensed pursuant in Ote Connectors
Liserse w.
exempt B A P C for this reafon
Danner,
WORKER'S COMPENSATION Ofthe fRAT10N
1 hereby will
uMtt penalty Of e perjury rare of the following deelket"Co
1 have anti will maintain aCmificM of Consent,Code,sure a pert rrea Compem (0
,ion,', which this
for mi Ss man 3]00 of the Labor Code,for the pertormena of the art
m'(ser which Nis permit is issued. V'1
I hem,ant will tmmasm Worker's Compensation Ind.,as"timed by Section `J
3]OOof the UWr Cade,for the performance of the work for which this permit is isancd.
My Workers Compensation Insurance carrier and Policy number are:
Curler Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' „
COMPENSATION INSURANCE
(This scan,necdrw,bccomplened Jibe proud is(mom hundred"Is ,(SIM)
on I...l
1 cenif,the,in ted perfmmeoce of the wmk forwhich this pemm is issuad l shill
not employ any penton in any manner.,as to becmne wbjeci to the Workeri Compen-
ou Laws of .Dau
Appheanl
NOTICE TO APPLICANT:If,aper making this C-mliicam of EumPao t.you should
become Subject o the Workers Compensation provisions of Ne Le Code.you most
forthwith comply with such provision ser this permit shell be clamed invoked,
CONSTRUCTION LENDING AGENCY
O I hereby aRnnthet Ncre iso cmwmcdo.lending agency for the perf,mama of
2 the wmk for which this pmol,is issuM(Sec.309].Civ.C.)
a 5 Lender,Name
Landers AiLdre,s
[kr' I caafy thin 1 have orad this applicnion and awe sew the above mromuaon is
a. cartel.I agree m,amply with all city and wumy indiums,and sum laws relating.
Z building cmnwcaon.and hereby authorise representatives;of this city to enter upon du
f) O sW,x..mmncj property fm inspection Ompoxe..
W (We)agree m save.indemnify and keep harmless the City of Cupertino against
O rJ liabilities.judgments,erose and expenses which may in any way acemeagalnn said City
} [k1
to consequ<me of the gnamil of this permit.
[•� d APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON'-POIN'I'
U SOURCE RECULATIONS.
SignemmofAWLicwJComrutm D.
HAZARDOUS MATERIAIS DISCLOSURE
Will the applicant m future Wilding attuwntatuinmhamile har«rJou.mate dal Re-roofs
as defined by the Cnpenina Mumcipnl Cade.Chapter 9.12,sena Ina Health sena saPory Type of Roof .
Cala.Section 25532(s)'
(]Yea ON.
Will ac applicsn,or future Wilding occupant use Niipmeat m devices which A foo . s ..tail prior to an roofi ern i being
emit herallouf•ir conumimnu ex defined by the Bey Area Air Quality Management installed. If a roof ism taming an inspection
°k°int' I agree to remove all new mater' or inspec
❑Yes CNo
Ih.ereedtbe h.�rdm.maerial.re«ai,amwta tinder chapter c95 afthe Cash-
Tumult un erstands and will com ith all non point source regulations.
Heald At Safety Cade.Sections 25505,35533 and 25534.1 understand thn if the -
bullding does nm ctmen0y have a mmm,that it is mY rcsponsibili,y to un ity au occupant
of the h t mrimmkmance oRCer,tee roof Oce m.
pi y � w r
'ryrt/y/may, YW +.O-rk -rd&you Signature pplicant Date
Ow
ser euNoused agent Dau
All roof coverings to be Class•B"or better
OFFICE