00030133 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTORINFORMATION:
BU ILDINGADDRESS:. )� I ��*�� J'Zy'5�� /' Y(r �� Q�
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ARCHI'nicl'IENGINEER - �yO/Z dIILDINf P1iRmir INFO
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f_ LICENSED CONTRACTOR'S DECLARATION
= I hereby affirm
tau 1 am licensed under
pmvisions of Chapser 9(<ommc Job Description
�HC;Ii wish Sation 70003ofDiviaion3of the BusinexsandPof 'onsCie,ai mylice //rte/s
in full nand eRect /, lee
OyU Lianm Clas `' LiON
Date Comoscmz
y O g ARCHrTECrS DECLARATION
I underasand my plana shall W used u public records
a _
Licensed!Prefeuimul
OWNER-BUILDER DECLARATION
C Z>' 1 hereby of irm that 1 am Hem's from the Conmacmex License law,for the
Yz C ruder inB rei�mt.(Seetim 70J LS.Bmims and Rot moor Cade:My city----Yto which requites a permialt m cro m i dreg Improve,derrmliah,of mPalr my suuetmq'e S Ft. Floor Area Valuations
3m pnormits ism.ma, so requires the apphi for such perout m(le I signedautentent
that he is licensed pariah,t"Ne provisions of tae Conmeaoma Lianxe law(CMae,9
(hatheisixemimseamnnwdmeIsieesforthduegedex,awon.An vioiabmof AI Numbs ccupancyType
Nu he is exempt thmefrom and the bums for the alleged exemption.to Any l'malty Of
Section 1031.5 ve any applicant deli for•pefmis subjeeu she applicant to a civil penalty Of 2 -
nm more Nen five hundred dollar,y employees
❑LasawMrnrmepra..mmycmptended imwages
eeifor ne(Sm.7(soleom.B.Zinmm. Required Inspections
will do Prliework,ande: he Comixnot Lt. or o.dofm We(See..as Business
si Hty w1hou Cie:The Conwami Liatue law dm ata apply s lf rtvrcr of
his o
property wed WiIN or anpaovcs thereon,ad who dm such iota himself of through
his own employers,'molded dw such mentis old w art ata Triode a offered for I
We.If,however.ll l buildingurimpmveoamtissold did sm,neyurwfmprovefor she
no.o Willa will have IW burden of proving that he did Hat Wild m improve for pm- /
of sale.). o�
I,u owner of the progeny,am sines andvely cofessi ns with:)7Dsa Aontaciama as i-
ceme La the project(Sec.o an owner
of and dy wh Professions Codr un,rovem ties ter.and
O
cense law docs Out apply m an owner of progeny who builds Or improve.thercnn,and
whasts far such pmlau with a wvacmr(q li
ncenced m pur,uato the Canuh
acso
License
LO
u aw.
❑1 am exempt under Sec. .B g:P C fa this heron
Owner Dem
7r37WWORKER'S COMPENSATION DECLARATION
1 hereby affirm under penNty,of perjury mre Oddie following declanfiam:
m`
I haveend will nuimalna CenificamofCOmem m alf-insure for WoraamY Compen-
tion us provided fm by Soman 37M of Ne Laboz Cde,for she For..of the
or which Nix permit is issued.
ff have and will meinuin Wmfker's Compensation Immo me,ex mquired by Session the Labor Code,fmr the pedurmm;ce of Bre work for which this permit is issue.Wder ai PolicyurPolicyNa.:CERTIFICATE OF EKEMMON FROM WORKERSCOMPENSATION INSURANCE
(This socion deed an be completed dIbe popeit is fmoa hundred dollar,(SIM)
r lem.)
I emir,use in Ne peffofmarwe of the work forwhich thiaperodt is issued,l shall
nes employ any Farm.in any ounce,w as to beconw'-him'as the Wmkerf Compcn-
at ion laws dcalifmnia,Data
Applicant
NOTICE 7O APPLICANT:If,after making thin Certificate of Eumption,you should
become subject to Use Workcet Compensation provisions of the Labor Code,you must
forthwith comply wit such provisions or this permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
QI hereby aRnn than thmeis a conswchiss lending agency for the Pcafornana of
Z be work for which this permit is issued(Sew 3097.Civ.Q
hander's Name
(� > t<oder's Address
tgI I certify that I have nal this application and mem that he those infocom ion is
IS. contract.l agree to comply with all city and county ordinances and cum laws relating m
:D Z building construction.end hereby iuthaia mixesenutives of this city to enter upon the
L) 0 abova-mm'runt property for inspection purposes.
Ra (✓ (We)agree to save.indemnify and kmp harmless the City of Cuivem m against
O V liabilities,jdgments,cmB and expenses which may in my way mme against said City
;,' W in conuqucm of the granting of this permit.
APPLICANTU 'DFRTANDS ND WILL COMPLY WITH ALL NON-POINT
V z SIIURCE RFf A L-16. 6
S0 I
SigirshourcufANNAlijWnricaur
HAZARDOUS MATERIALS DISCLOSURE
Will the applicenforfuture Wilding mmpm strum or handle Nsdous metedil Re-roofs
wv defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety T e of Roof
Code,Section 25532(a)? _ / .yp
CYes
Will ser applicant or future Wilding occupant use ep"prtem or devices which All roofs shall be inspected prior to any roofing material being
krait hazamdous atr conuminanm as dcfred by the Bay Arca Au Quality Managemtent installed. If a roof is Installed wit ut first obtaining an inspection
omict7 I agree to remove all new mate s for inspection. Applicant
❑Yes
I have trail the Immunities mamdila ImI "dem Chaapter 695 Of the Cali- understands andwww 1 cote 7th all non point source regulations.
tomo Himlth S,Safety Code. Nom 25 533 ai 25531.I uodemand fast if the
Wiliingdasnacts a mnn atR is my rtapomithday m not dm Occupant
of the myuircmems w da m issuance of a ccrut In
Signature of Applicant V Date
Owner Or authorize age m
' All roof coverings to be Class"B"or better
OFFICE