00020150 CITY OF CUPERTINO PERMMNO.
BUILDING DIVISION PERMIT CONTRACTORINFORMATION:
RLILDINC ADDRESS: 019
1 SANIIARYNO. APPLCATIONSUBMITTALDAiE
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LICENSED CONTRACTOR'S DECLARATION
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0=O 1 hereby aRmd Net 1 am It coned under provisions of Chapter 9(commencing Job Description
I—ou with SochiJ000),IDivislw 3ofz BuslMsa sued professions Cede.ed my license is
c� < in mer rorce.nq.e F_ 6
0,U
Liceve Clao Lic.N
i 3 N Da¢ Q3is-
TS DE ATI P rf
dys"I ECTS DECLARATION /
y— 1 wdemrud my Dlw shill bo used as Public records
s Oe Licamd professional /
_ OWNER-BUDDECLARATION DER DECLAR /u✓P /�� ,/ /- o
F- a 1 hereby off.that 1 R-exempt from the RATION License,Law for the
S O following mason(Section 7031.5,Business and Professions Cods:Any cty or county
3$ which mqumas a pttntis m construct,slier,impmve.demolish,or mpatr any swnrc
uSq. Ft. Floor Area Valuation
Fnw m its i,suena,ilm requires she applicant fon such pemut m Ele a sigsed summcm
that he is licensed pursuant to the provisions of the Contractors License taw(Chapter 9
(wmmnming with Sedco 700B)of Division 3 Of the Business and Pro(easiov Cda)w APN NbOCCU
that he is exempt thamion.from and the basis far the alleged esemptAny violation Number . Occupancy Type
Section 7031.5 by any applicant fon a permit mbjwm the applicant to a civil penalty of
pd more,Nan five hundred dollars(55001.
1,aanwnerartepmpeny.wmycmp9yaawiNw,guasNeirwleampcvdw. Required Inspections
adddofework,road :"ato mmisera imanded Lawdofon We(Sec.'.an most,
and property
who
Code:The vas therm a Have law saes era'Ply'.an owncr M
property who build,or improves tharcen,and who Baca such worst himself of through
far
his own employeese provided r improvement such imprIs old w am not imendd or oRerm for
uta ILbower witobuildingor .of Frmsla sold did one ywofcompletion,Ne
pose.f uiMtt will have Nc human of proving Nn he did not build w improve fon pw-
0 1 of ole.).
L u,weer of the Dropeny,.Bexclusivelyand
contracting wish licensor ontpwmss i-
cumquat the es ma (Son.?OCs,Buaimas and professions Code:)improver
er thecmr'e Li-
who Law diesnotapply1.jetsownet orprc.0 who builds Or impmvee thereon,road
whocontractsfor such projects wish a contaacmgq licenrd pursuant m the Conuwmre
01 am law.
❑1 am cxampt under Sw. .B k P C for this rtasmn
Owner Dem
WORKER'S COMPENSATION DECLARATION
1 hereby aRnn under penalty of Perjury one of the following declroauov:
I have end provided!
far by Section 37M of the
Labor Colo.sum for WoherY Compcm
anon,as pmvidd fon by Becton 3'/00 of tie labor Cade,for the perfornuwe of she
woh fon which this pandit is issued.
1 have and will maimain Wmkds Compensation lasursocc.which
as required by Section
l?OOof Ne Lehr Cede,for the performance of the work for which Nis permit is issued.
My Worker'�Ctton mMigNn�uranccppmc end Policy ramp
Carrier: TRM _Ol Policy No.: ! (e
CERTIFTCAtE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Ibis section nem not becomrletd i(Ne permit is far.hundred dellen($100)
or
Iran.)
I unify drat in the peHonnana of the wwk forwhich Nie pemrI is issued,l shill
not employ ad,person in any manner w as to become Fabjwh w the Waheri Compeer-
sstion taws of California.Dam
Applicant
NOTICE TO APPLICANT:If,afar making Nis Certificate of Excmptiom You should
become subjecno de Waters Compensation provisions of Ne Labor Cade,you most
forthwith comply with wch provisions of this permit shall W deamd mroked.
CONSTRUCTION LENDING AGENCY
I hereby aRnn ton tache is a construction leading egcncy fon the performance of
,Zz the work for which Nis permit is issued(Son.3037,Civ.C.)
(•. Lenders Name
a Ceders Address
(y) I unify,Net 1 have mm this application and store that the above infornutim is
0. Q correct.)agree to comply with ell city road county ordinances said sum laws mlating to
7 Z building concoction.and hcmby audoner rcprcsemaivey of this city m ensu upon the
U O ahoy-menemhd property for inspection loops..
(We)agree to ave,indemnify and keep harmlassme,City of Cupertino against
V Iiebibues,jndeco
goms,costs end eapenses which may in y way wane against said City
} W in consequence of the gaming of this permit.
[•. APPLICANT UNDERSTANDS AND WILL COMPLY W LTD At.].NON.POIN'r
V z SOURCE REGULATIONS.
Signature ulApplican✓Conmectw Dam
HAlARDOUS MATERIALS DISCLOSURE
Wills ,applicant or future Wilding occupant some or handle havdoua mammal Re-roofs
as deBncd by the Cupertino Municipal Cods,Chapter 9.12,end the Health road Safety T e of Roof
Cela Section 25532(0? yP
❑Yes ❑No
Will the applicant or future building Occupant we equipment w devices which All roofs shall be inspected prior to any roofing. material being
emit haoddus wom
air cloau nu defnnd by the Bay Ana Ab Q.911,Management installed. If a roof is installed without first obtaining an inspection
Di,.,? I agree to remove all new materials for inspection. Applicant
OYw ON.
1M,eread!the has,ads,materials heuimmemaunder,chapter 695ofthe Call- understands and will comply with all non point source regulations.
forma Health R Safety Code,Sections 25505,25533 and 25534.1 underslroee that if the
Wilding does non curmnty have.mount.dust it is mY msponaibilitY to notify the-'-W- C/
C/
of the rcy---er mush. be ma plowmssuance of a Cmi /7 `Bvy.
-f.-fit/L� / Signature of Applicant Date
Ownin,wauNonad agent Dam
All roof coverings to be Class"B"or better
OFFICE