00030169 CITY OF CUPERTINO PERMIT o.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0
BUILDING ADDRESS: ArI /
SANITARY NO. APPLICATION SUBMITTAL DATI
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`; A«I+ J rvtc CONTAOLM
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ARCfIIT1iC1'/FNGINE[R BULUINO PERMI"f INFO
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N= LICENSED CONTRACTORS S DECLARATION
o z=e I hereby affirm thatthat1 am licensed provisions of Chipset 9(commenting Job Description
with sxuo of Division3 of Ne Busin<ssantl Pmfotiona CodM e.amyliccnse is
< s j in fun racla and ad(I'fedea.
u.a Ilceve Class Lie.
+�'3 u o, O m COn
ARCHITECT'S DECLARATION DEC
ITLARATION
.J 1 understeM my plans"I be used as public temrds
O Licenxd Profevionel //,ems
v, OWNER-BUR.DER DEe_hRADON
t_i r 1 hereby aRtm Nan 1 am exempt from Ne Contractors Licenx taw for the
d CO follcuing reason.(Section 7031.5,Business and Professions Code:Any city or county
3 wNch requires a Form in comm ct,ahcr,improve.demolish,or repair my swcmre Sq. Ft. Floor Area Valua[iot�
primm its isausece,4.rtquire,the applicant fumes permit m file augmdautement J e-L)
Nmhnislicensed pumusnuo the provisions of Nsase ta
e Comctors Licenw(Chapter. 9 / 000
(commencing with Section TOW)of Division 3 of the Business and Professions Cadc)or ApNNumber occupancy Type
WNm th
t be is mempt aerroand the basis for e dlcFd exemption.Any violation of ` p y 'J'p
S.mm 7031.5 by any applicant for a pcmtil ml jecv the applicant to•civil petWty Of
fxfive hundred dollav 5W).
❑
Required Inspections
waldothc weak,ant the macmm is not intended ne offered finale(Sec.7W.Bounces
and Professions Code:The Contractors License law does nm apply m an owner of
property who build,or impmves intention.and who does each woes himself or Nmegh
his own employ.,,novidd are each improvements are nm intended Or offered fee
sale.If,however.the building or improvement is sold within one year ofcorepIcWn,the
ner-Wilder will have rhe burden of proving,het W did not build or improve for per.
poauf We.).ocui
oc lda owner Of rel property,am met,and
conbcting with Ilcen,ed conmamon U.
'J
or.Imtheproject(Sc.O. vur Of and.ywhoiona Code:)The Conn...W. s
come Low dace not applyje ts owner of mopeny who builds or improves Conten.and
who contracts for such projects with a conoacnm(Olmcnaed pursuant to Jte Conummrs
uen
mncxcmmun is.. —I a�1'—..�J� BRPCfm this mann
Owne .N `y— Date
WORKER'S COMPENSATION DECLARATION
1 hereby Mrm under penally of perjury ane of Ne following declarstiom:some. \\
❑leve ask will Toby nee tion 37M ofCe Urso,Code.
ft WoheraComma-
workf r providedacthis
fpe by Ss ksm 37W of Ju Labor Codc,fm the per(omunee of me
work for which this permit is issued.
❑1 have and will maintain WaM1 Compensation w rk far whi as required by Section r o0
My ofkers Co Nnmtim led[amounts
which this permit
My Workers Commnatian Inmretme cam.and Policy number art:
Coder: Policy
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This action need not h completed i(Ne pemu'n is feaonc hudtd dollars(51 W) �
or lea)
I certify that in IW peiformercre of the work for which Nit peri,is issued.)shall
nm employ any penton to any manner m u to become subject m the weaken'Compen-
sation Laws of Cdiforoia.Date
Applicant
NOTICE TO APPLICANT:If,after nuking this Cemifcac of Esamptims,you should '
become subject to the WoAera Compensation provisions of the labor Code,you mutt
herb.id,comply with such p.v„ions or this permit shall W doomed revoked.
CONSTRUCTION LENDING AGENCY
p Ihereby affirm'
hat there is a comantcdon lending agency for the perfonnanm of
Z the work for which Nis permit is omed(Sc.3097.Civ.C.)
Lenders Name
> Lenders AM ui
Ors) I cenlfy than 1 have read Only,appli sainat and sure that the above infomution is
1 come,.)agree to comply with JI city ant county ordivn.a ad auu laws relating m
Z) Z building comrmcdon,and hembymdusis represenmiwa ofthis city to mar upon the
V above-mentioned progeny for inspection purposes.
(We)agree by save.indemnify sod k.p harmless the City of Cupertino agaiml
0 t.) liabilities,jdgmenm.emu ad expenses which troy in my way mane agarmt said City
�a W in conuquence of the granting permit.
t APPIIC UNDERSTAND. D WIIJ.COMPLY WI Of ALL NON-PONT
V Z SOURCI RI UAATIONS.
1
ignaturtof AppllcantiConcracuur D°fe To Y4"ti70 A-4--cCC.r
HAZARDOUS MATERIAIS DISCLOSURE
Will dre.mitcmn or future Wilding occupant mare mludle haeallous material Re-roofs
as defined by the Cupertino Municipal Code,CWm,9.12,and the Nesbit and Safety Type of Roof
❑Yes
Code.Secure25532(a)f t7� yp
Will the applicant or future Wilding occupant on equipment or devices which All roofs shall be inspected prior to an roofing material being.
Ah m,h.udnusakco mumant,a,deRmdbyJwBayAreaAuwdity'Mmagemam installed. If a roof is installed without first obtaining an inspection
Diapift7 I a ree to remove all new materials for inspection. Applicant
Yee g
)n h.remddaba de.ma� ymwimm teed Chapter 695nfm Ga i- understands and will comply with all non point source regulations.
fomia nen Selny C , ,don,25505,x5533end 25536.1 understmd Nat if Ju
Wilding dors currently tenant.Nm in is my respere6bility to notify the occupm,
the mluve mw urn ameof.cenin.uofOScugncy.
Signature of Applicant Date
Culler or affilhonted agent Uau
All roof coverings to be Class"B”or better
OFFICE