00050035 CITY OF CUPERTINO MIT NO. _
BUILDING DIVISION PERMIT CONTRACTOR,INFORMATION: U�b � U ��
BUILDINGADIIRESS: �g rH � WTCjjp7i V
SANITARY NO. APPLICATION SUBMITTALDATE
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ARCHITECTAINGINEGR BOLDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
zanz 1 herebW
yarfrm I 1 om licensed under proviuons of Chapter 9(commercing lob Description
F:_v. with Saewn7gp)of Division3of dm Bminessand Rofessione Code.andmY littnse is
MSS'u in full force and Act K.gr T Ci1A5V
C u Littnse Chess -S tic.♦ fly-elm��(e� .
3>H Dam Co..
C O gARCHITECTS DEC RA
a5 1 unmerited my plana shall W used as Public nocerds
i S o Licensed Pmfessiterse
OWNER-BUILDER DECLARATION
1-z- I hereby aRrm Wt I am mor,from the Commeora License Law,for da
m O following mason.(Section 70131.5.Business and Professions Code:Any city m cmnty
3� which re9nires.pemnil to cnmt,uct,dtee;mpwve,demnnah,nr rtpJr my m itswam Sy. Ft. Floor Area Valuation
prim s issuance,sent nominee applicant for such permit we file a signed snmmem ee'']')
Nm he is licensed panuant w the provisions of ern Contractors License law(Chapter 9 .90,C:10.O
(cumbeencingwan Section 70o0)of Division 3 ofthe Business and Professions Cod0or N
NN e —n Occupancy T al he is eaenurnd thebas
t therefrom art is for the alleged exemption.Any vholanmm of ane V / / P Y YPe
Section 7031.5 by my applicant for a pmtil mbjaa lite epplicanno a civil pnalty of
m mote than five hundred dollar
(5500).
m
I,mnwnernrlWlwpnr.mmremphnyttawithwsgamNenroleenmpm.tion. Required Inspections
will doeW work.and the structure is but;ntendedoroffeml fm we(Sm.7011.Business
and Professions Code:The Contractors License law does nor apply to an owner a
pmpcny who builds or improves Neram.and who does such work himself or thouugh
his own cmph,on,protruded than such imposemena art Inst intended or offered for
We,If,however,the Wilding or impmvemrnt is sold within one ywof eampledon,the
merever,innilde,will have the burden of proving dem he did not Wild or improve for pur-
poseofWe.l. se
I.m owner of the property.am eacsively coommung wide mm
bummed contractors to J'��
cons.,the projat(Sen.7(1 Business and Profession.Code:)The Compactors L;- �aV\
came law does not apply to an owner of proper y who Wilds or improves mention,and
wed course for such .*"with a cootr Im(a)Neenah pursuant to Ran Conoxmea O i
License Law. O
El 1areexemPlundersn" .BRPCfm Nismason
Owner Dem
WORKER'S COMPENSATION DECLARATION
IherebyiL] miunderpmaby ofperjury onsof tfinwmingwa esC
1 M1ave end will for byn•Cion 37M of Covent mCodenmm fonwmtrh Compo
ssei k l ns provided for mi Section 3700 or Ne Labor Code,for the perfowenoe of the
k have
which this pewit is issued.
1 hath and will maintain WnAers compensation de,w rk for which
ss rtquirtd by satian
ofthe labor code,for Jan prfom+auce of Jac wort for wni<n Nie permit i.issues.
MY Wor�l Co pe t<I -�mc��emya9�+ ma Polo: L'� ')32 C
Camieq)gL L 7�XEMP Policy No.:1_r{7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION Ie SURANCE
section rte completed stieu necompleteddthtid am,ir is rorone Wndrtd edl.rs(sho(y
mlcss.)
1certify perp in my mmmser of thework for which this pewitrI CoIshall
rotr mUw any prion in any manner...w became subjat to dm Worker'Compeer
AppleLaws of California.Dam
Applicant
NOTICE TO APPLICANT: a Co making than Cisions te de Labou o d you should
become scomt to be Workers Cnmpor this positions or dm labor Code,yon must
forthwith comply with such provisions or this permit shell M dttmed revoked.
CONSTRUCTION LENDING AGENCY
Q O I hereby affirm than Nem b e construction lending agency for performance perfounce of
Z the work ran which this pernut is issued(Ser.3097.Civ.C.) _
CL Lenders Name
s Address
tai] ? Leader's
certify We I neve mad this application and mem thal the above information is
1 12 comi I agna to comply with all city and county ordinances anal sine laws retailing an
7 Wilding construction.and herebyauehorim mprerznmives of this city in enter upon the
V eWvemenlioned property to,inspection purposes.
fir. F' (We).gra w ave,indemnify and kttp limbless IN City of Cupertino egaient
V Iiabilitim.jndgmmna,cmc and expert which may in any way saeue Memat aid City
'. W in consequence of the grmting of Nis pewit.
H L APPLICANT UNDERSTANDS AND WILL COMPLY W TOI ALI.NON POINT
V Z SOURCE IGU1LA'IONS
/.
ilArT�
Sigtlamrt al Applicarel mama. Dam
HA AARDOUS MATERIALS DISCLOSURE
Will theepplimice,fuer.Wilding uccopem nom or handle"eardmes material Re-roofs
we defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety Type of Roof
Code,Section 255321.)7 YP
❑Yon 1)410
Will the e,licart or future Wilding occupom use e9vipmem or devices which All roofs shall be inspected prior to any roofing material being
emit hmudcus air contaminants.,defined by the Bay Arcs AB Quality Management installed. If a roof is Installed without first obtaining an inspection
mi°e'
❑Ya ��L��`eeewww'''��� 1 a vee to remove all new materials for inspection. Applicant
(3yvo
I have rad the named trials mquirtments under Chepa695 of Nc Cali- understands and will comply with all non point source regulations.
forma Health k Safety Code,Savona 25505,M533 surd 25531.1 understand that if be
WildmgI snd cu ly lave a tenant,that it is my responsibility m notify Ne occupant
of Ne gg a an�.�fPnwwiseuome of.Ceriicmhu Occupancy.
Kt. t — tWi2r. Signature of Applicant Date
cath edgerate.
All roof coverings to be Class"B"or better
OFFICE