00040003 CITY OF CUPERTINO - PERMITNO.
xuiLDDNC DrvtswN PERMIT CONTRACTOR INFORMATION: ��J 1(\
BUILDLVG ADDRESS: N/g/ I/1� `�r�� AV,/
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/ 1 �� /�/ /(,,J ///GJ/ U SANITARY NO. APPLI NSUBMITTAL DATE
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El
ARCH � GINIiE0. - (/�1/L/arf5 IV) L� /`i� s
—/ BULDING PERMIT INPO '•Cx
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F-H i LICENSED CONTRACTOR'S DECLARATION
z O yr� 1 hmby affirm Nat 1 am IlGrnsed unit provisions of Chaptu 9(comme«ing Job Description
Fytw I.hll Face andlO ecDwision3 ftheBminessan f ode.mdse lianuis
< o' in NII force and affect.
�� y hi//���
3 4 N Dem CTSDECLs
a O; ARCHITECTS DECLARA o N
l uousoo my Plw,hall W coed Is public ruonls
a.o O Licensed Profasslomal
uaS- OWNER-BUILDER DECLARATION
I hemby aRrm Nal 1 eexemptth
m from e Coatractoh License law for the
+d S following mason.(Section 70313.Business arts P�ions Cade:Any city a county
which r uims a permit m consumer, her,improve,demolish,or repair my someone
li� Sq. Ft. Floor Area
prim m its issuance,shm try one,she applicant for Inch prmul to files sig«d r atemrnt
that he in licensed pursumt to she provisions of the Comractor's license Law(Chager9
(cormnmcing wish Smdon 7000)of Division 3 of the Business and professions Cedc)o APN N b r Occupancy Type
Nat he is crampt Nuafrum and the India for the alleged exemption.Any violation of _ }tf I b P Y YP
Section 7031.5 by any applicant f«a permit subjects be applicant m a civil pmoi of 21, G
not mom Nm five hundred dollars($500).
C L as owner of the property.or my employees with wages u their sole compensation. Required Inspections
will do do,work.and the ao
mumm is nm intended oRcr<d for We(Sa,,70a6,Business
eco Professlom Code:The Contractor's License Law docs rot apply'.an own,,a /
propmy who Wilds or improves Merton,W who does Inch work himself«0uoueh
his own employees,provided Nat such improvements sue am intended or offered for /
We.If,howascr,the building or improvement is sold within one year mf completion,she O
owmerWilder will have Jre Noun of pro in6 than he did Inst Wild or improve for per- /
pose of ssle.l.
C 1,u owner of Ne property,am exclusively conrudng with licensed contractors to
construct the project(Sec.7Da6.former;and PmfeWom Cade)The Conwuor's li-
cense Law does not apply to m owner of propmy who Wilds or improves thacon,and
who contracts for such projects with a conractoNO licensed puratint m the Conracmis
license Law.
C 1 un exempt under Sec. .B R P C for this reason
Owner Dat
WORKER'S COMPENSATION DECLARATION
1 hereby affirm oder Finally of pe Puy o«of dr following deeBmtian,:
J 1 have end will maintain a Cmificam of Conunt m self-imum for Workers Compete
section.as provided for by Seedon 3700 of Ne Labor Code,for the performance of the
xfor which thin permit is issued.
have ao will maintain Wadonrs Compensation Insurance,in requirts by Smo m
of the Labor Code,for the perfminumc<of Ne wok for which this permit is issued.
My WorkerIj�' and Policy mmW/��/t _
Cartier. h1R1 CL—Polk No.:�4� J
CERT FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(this...minding beconplued ifmc pnroit is fororrhuWred"Ims(SIM)
or In..)
I ernify Nat in the pedorma«e ofthe wok for which his permit is issued,I shag
not employ my person in my men er m as to became tubjuno the Workers'Cramer-
union
ompen-
Wion laws of California.Dare
Applicant
NOTICE TO APPLICANT:IL afar making this Certificate of Exemption,you should
become subject to she Waage,,Compensation provisions of IW Labor Cade,you most _
forthwith comply with such provisions in this permit shall b,deemed revoked.
CONSTRUCTION LENDING AGENCY
1 berrby affirm am Neon iso comwction toning agen<Y for da parfortn,nce of
z tye work for which Nis permit is Issued(Sec.3097,Civ,C.)
(~ Lenders Name
s5 7 Landers Addrets
[7,] I emufy door I have read Jus appliation and man Nal rhe aWve irJomutim is
6 zcontest.I agree to comply with all city rrd county oedin,mandm ama laws relating to
7 Z building comnuctim,and hereby munition representatives of this city mentor upon the
V C above-mentioned property for inspection purposes.
Ing. t w (We)agree in save,indemnify am k«p hmnleas the,City of Cupertino a i mt
U liabilities,jadgnoms,cosu and I.,m s which may in my way accrue egmon said City
�... Lk] inconsequmc,of Ne gmmin6 of this permit.
(• 0- APPLICANT UNIIBRtirANIISANDWILLCOMPLYWI'I'IIAL.LNON.P IINN'I' �/
U 4 souRCE ner:ulwTt c51&-Idv
SiBvfVnue\of�A —amUCoLr nor Daa OC'_ I�A/7JIL CCS/ .
AlA0. ATERIALS DISCLOSURE
Will Nc epplimnr or future Wilding«mupam some or handle Intend—maanil Re-roofs
ae definedby the Ctopmino MuniyyyNNWI Code,Chapter 9.12,sad thW and e I d, Safety Type of Roof
Cade,Section 255321a)? YP
OyerNo
Will the it'licmt or boom,Wilding«c owl use equipment ear dkviccs which All roofs shall be inspected prior to any roofing material being
end,hamdcus air contaminants as defined by the Bay Arca AJ Quality Mmegcrramr installed. If a roof is Installed without first obtaining an inspection
❑Y<s g I agree to remove all new materials for inspection. Applicant
I hove mad the haaardons maanms mquimmmu took,Cba r 6.95 of Ne Cali- understands and will comply with all non point source regulations.
forma Health At Safety Cade.Section,25505.25533 and 25536.I understmd that if the
building does na enmity boveaWe .and it is my responsibility m notify,the«cu r
of the icniucmentaw 'a oustWort powmueueme o1aCmificarc ofOc
Z Signator of Applic a Date
Ow«r m autBorfxed agem Dam
All roof coverings to be Class••B"or better
OFFICE