00040091 CITY OF CUPERTINOP D RMITNO. I
BUILDING DIVISION PERMIT CONTRACTOR'IN.FORMATION:
BUILDING ADDRESS: �0 0
/ _ ♦� ��/t� / SANITARY NO. APPLXATI{O�NSvUBgMITfALDATI
( IiH'S NA E: /v I/1 �Q��f ^fe- L�—/ f V
�C J�NI �yyS NIC CONTROLN %/
PILONE: �O� e (/`J✓ V u-w I ��. � C/Y) Ip'!r'-J��N ElOO �/
AM[TSRf:CYIENGINEER !�J~ /
BOLDING PERMIT INFO
�oo /VIDES �✓y. ��� • F5`�LZ� o ( � 6 • �
tat^ LICENSED CONTRACTOR'S DECLARATION
OZ_G 1 heeeby,Rnn mai I w Lamed under pmvium s of chapter 9 mommercwg Job Description
t,Id(nj withSa rmandac Division]of me Businma asM PS klti mYlianx is /1 YY ��M/ SPA—
E:<y a J n Poll force uW effect. //\'Ulf l`\V,I'I/JI ,aa' N 1Y('�"�
ow IicenuC s Lich �k ' 1 /.
.'3 te N Dtlle eOnWcbr ,v 1/� `1
CTSECLARAT16N
and Ids u public rccadr
utea 5o
c¢S y OW E BUILDER DEC TION
F i a 1 hereby aRrm that exempt from the ComeactoYr Licenx law for the
`z O following reawn.(Section 7031.5.Business tad PmfeWwa Cade: ray city«aunty
udai�-$ which rryui,m a pmnit m comtrlab alcor,improve,demotion upair any avumure
j— prim to its i.suma.also reactions me.ppGc.If«such pe Ele aaigrrdautement Sq. FI. FI00 Area ,^ VaIUHIl00
met he is lim.d Footnotes to me provisiomof the Conv aU.ma av,(Chap 19 / 2�
(ammmdngwimSaition7")ofDlsisien3ofine emruWProrerim.code)ae APNNumbe Occupancy Type
mat he u erempt therefrom and me basisform Iagad exemption.Any violadon of
Salon 7031.5 by any applicant f«a Pemtit jeers the applicant to a civil penalty of ��D v
pt mom mm five hundred dollen(5500)
L,sownorafinepmpeny.«my, aymawithwagesadmin.aleemnprmw;m, Required Inspections
willeothewoek,aedmesvucmre i. tinteWed«offered fa Wc(Sai.7000,Business
and Professions Cods:The Co con's Liame Law docs not apply to m w.a
Property who builds or it thereon,and who does such wort himself or through
his own emPloyem,provi that such improvements art rout Intended or offered for
sidalf,hwnism it cbu' ing orimprovarmmis Wd within meyw of rompluim,dte
r-Wildawill me Wnden of proving th.t he did..Wilda,improv forper- /
priu m tele.). -
❑L n owner me property,am exclusively convecting with littnsed contractors to
c mouth the ojat(Sec.7000,Business and Pmfessiom Code:)The Convector's Li-
cense law s not apply ro an owner of property owed Wilds m improves meson.end
owed con rs fa not apply to a owner
of property
who
pumm�t ro es them n.and \
Liccn w.
❑1 ea<mpruedcrS«. .B&PCfor misruwn c 1
Owner Date
ATIO
WORKER'S COMPENSN DECLARATION
1 hemby affirm under penalty of perjury ons of the following declarations:
El lhaveendwillmainWns Ce ftteof Conmttowif-inmmforWorkersComprn-
I satin.,as provided for by Section 3700 of me Labor Cade,fm the performance of me
work for which mis permit is issued.
1)WM/1 have and will maintain Wmkcr's Compendium Ins«ance,es,equina by Swim,
.Rof me Le s r Cade,for the perramomee ofine work for which this permit i,issued.
My Worker,Com ration Ina carrier and Policy num e'
a
Cartier: I Policy No.:
C C TE OF EXEMPTION PROM ORKE S'
COMPENSATION INSURANCE
(This samon madmr bemmpbeed ifthe tamed is forme Wassail dated,(SI W)
or It..)
1 certify mat in the performation of the work for which this pamet is issued.I shall
cot employ any person in any manner m as to become subject in the Worker'Compan-
sarion Laws of Calif crew.Data
Applicant
NOTICE TO APPLICAM':If,after making this Certificate of Examined,you should
hecome subject to me Weame.Compensation provisions of me Lahm Code,you must
forthwith comply with such provisions or this permit shad)be claimed revoked.
CONSTRUCTION LENDING AGENCY
Q 0 I hmeby affirm mu dens is a cownWetion lending egeraT'forthe perfomtarcca
Z the work for which this permit is issued(Sm.3097.Civ.C.)
rA Lost Num
lender,Address
^Q
W I candy,that 1 have nand mia application and alae Chet me above information is
0. comet.I aga rto comply with ell city and county ordinances and suv law.relating n
z, building construction.and herebyauthodu representatives oflhis city to enter upon the
aWw".nomioned property fee impecum purposes.
k. F. (We)sera to nave,irWcmnifY a P ha,mlces me City of Cupertino agaiou
O f) l'ahilities'Wgmenv,cosh eM expert hich may in my way,cweagilnxl rid City
>a W inc clean,
fthi ,mit.
I" 1 A ' 'ANE,.ER.. N ti WII.1. MPI.Y 'ITHAI.I.NONMINr
Sl)U ,C REf.ULATION.
z N L �pJp
Signatun.[Appli<anJContnc r Dag ./Y♦ aTQ v(� f r 1
HAZARD US ATERIAIS DISCLOSURE, d I +`^ r
Will theappimust or fm eWil ing«cupem emu or handle hazerd9ua material Re-roofs
u ddoed by the Cupenind Mu 'i a me.Chnpar 9.12,and the Health and Safety
Crede.Smith 25532(.)7 Type of Roof
Ves
Will me.pwieantarfama Wilding«apant use equipment adeviarwhinh All roofs shall be inspected prior to any roofing material being
emit hardoaircontaminants,m contaminandefined by the Bay Arta Air Quality Management
vm installed. If a roof is Installed without first obtaining an inspection
Distrfci7 I agree to remove all new materials for inspection. Applicant .
Yr g
c thehavr a ClnprerR95 de �. understands and will comply with all non point source regulations.
form, fa1N Safry Code, t 505.25533 cl 25 .I eMus. than i the
ng on ctcJuve en Lmat Itis mY iliryt
a ray 'e which be'in iv f Ce m c� VD Signature of Applicant Date
Ow"'
o[evthodud ege0t Date
All roof coverings to be Class"B"or better
OFFICE