00030110 CITY OF CUPERTINO PBRMrr No.
BUILDING DIVISION PERMIT CONTRACTOR
CONTRACTOR INFORMATION: . 0 � b I I
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22 C', SANITARY IN APPLICATION SUBMITTAL DATE
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TECT/ENGINEER 9Vo L13 BULUING PERMIT INFO
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LICENSED DECLAMTION
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Z O y P CONTRACTOR'S
:hneby af0rm wt 1 un R,anea.neer proWaiava ter Cnapat 9 eanennving Job Description
�<mFS-u� wish Sectionard ncf Division 3ofNe Lec.I ad Professions Code.ad myliunuis ,f �s
C 0 U Li..corce.nd eHec�/ q Lic.« �///i a�r�.C.P "A—�"T/✓
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eOmDE Q . .I�IC
t u O¢ A0.CBITECI'S DECLARATION U N �VgA.yr
..1 I und,ntvd my pians shell M asd v public records
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o, OWNFRBURDER DECLARATION !/
l-z> I hereby aRrm Nat 1 am exempt from the Cortrwmrs Licenu law for the
j6€O follova ng reason.(Section 7031.5.Bnsirwss and Professions Cade:Any city or worry
i. $ which reaffirms a permit in consuun,eller,improve,demolish,or repair any nwemre
'- t its the. ant fmwcn ftofileaxi dsancmenl Sq. F . Floor Area Valuation
prior of requires applicant pemti gee oo
Net he is licensed punuantm Ne provisioro of Ne Contrwtora License Law(Chapter 9 Og,�0 /0 (S/•
(cummcncing with Section 70001 of Division:ofth,Busiaaaad R.&uiom Code)or APN Number Occupancy Type
sol he is esempt therefrom and the basis for the alleged exemption.Any violation of � P Y YP
Section 70313 by any applicant for a permit subjects the applicant to a civil parially of S 9► «\IAA x y -0 2 VA
a.Nan five bnrdred dollars(5500).
(]I,vane,vofdeWopenY•ormycmPlgeawithwagauNcirwlecompewtioa Required Inspects
will code,work,and the suumure is eta imendcd orolfead for sdc(Sce.7066.Bodwss
and Profaaions Cade:The Conuwtori License ppl
Law does can apply to an owner w
Propertypropy who builds or improves Neremi W who does such work himself ce through y«
his own employes,Provided the such improvemwu art not inadd a offered for
ole.IL hwevec the building or improvement la sold within ane yevof completion,the `�"1/,'(
ncrbuilder will have the burden of proving that he did not build or improve for par-
sole.).
1,construct ower of Ne property,am ll..and conuacdng wia :itched ncrom mem /
om,Lathe es arm appl(Socy
706«.Business op rt,who Wicons,lda
Coe,:)The e,moment.
n
cense few docs rant applyje o,with
a of property who sed p m improves therwv,and
whence Law,for well poles with a conuacmr(q licensed pannsm to the Cwuuwrs �/O
Licence ant law.
1 em exempt oder 5«. .B&P C for this town
Owner Dae
WORKER'S COMPENSATION DECLARATION
I hereby sifirm under penalty of perjury one of Ne follwine decimations: -
[]Iheve end will mainWne CenifcaaofConunuoulGinsumforWmker'cCompn-
ation,as provided for by SeNon 3700 of the Labor Code,for the performance of the
work for which this permit is nomad.
Y1have cod will maintain Workermia
s Compemn Insurance,ss rtauirtd by Section
of do labor Code,for de,prfortnautt of h,work for which this pm it iis/iswd.
My Work!r�4 �e tt wel
nruw kmer and Policy g C
m
Ca 'a: (a�a�• Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thir sectioh rad not becompleted ifda prom is forum hadrd dollen 151(K)
or less.)
1 certify that in the performance of live work for which this pemut is issued,:shill
not employ any person in any manner w as to become wbjet to the Workers'Comp,n-
ouion laws of Calimaia.Date
A"Iwam
NOTICE M APPUCANf:If,after melting this Cci ifcate,of Exemption.you should
Wo.mbja'm the,Wmikds Compensation provisions of the labor Code,you it
forthwith comply with such provisions or Nis permit shall W domed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that then is a consuu,ni n tiding agency for the peffomeatw,of
Z the,work for which Nis Felon,is issued(Sce.3(397•Co,C.)
F Lenders Name
ai 7 Led,rs Address
r� I certify that 1 have mall this application and state Nat Ne above information is
0. ° conn"1 mgrs to comply with all city",.my ordinances and mac laws aladng m
Mending construction,end heaby authorize rtpresentmiva of this city w comer upon the
U O abovcm,miond proprty for inspection pi tposea
L. E. (We)agree to save,iM,mnify ad kap humleu the City of eupertirro silence'
O U heirllti,s,julgmcros.ems and expenses which may In my way stens,against aid City
in conugacn,of the granting of dis permit.
F" APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON.POINr
V SOURCE EGy'�+�TUNS.
Z•C n� -� 3li y Lou 4 , g
rti SignswaulAWxnUCcmrom Usa O w70�UC /
HAZARDOUS MATERIALS DISCLOSURE
Will ft epplicwwr boom building a:cupwtnoaor hadin huadoas mncrid Re-roofs
v defined by the Colston.Muddp.l Cale r 9.12,and Ne Health and Sdvy Type of Roof
Code.sec'ian 25532(a? YP
Vcs
Will Ne applicant or future wilding acupwnr use equipment or devices which All roofs shall be inspected prior to any roofing material being
,mit blossindows dr conaminanta m defined by the Be,Atea Air Queliry Mamgemem installed. If a roof is Installed without first obtaining an inspection
Die°ia" ,W.,J.'..// I a ree to remove all new materials for inspection. Applicant .
❑Yes
I have read the haterdoas motandsreaumm,ntx alar Chapter 6.95nf the Cali. un erstands and will comply with all non point source regulations.
fano Nealth&Sdey Cae.Sections 25505.25533 ad 255 W.1 understand Net if dee
Funding doe ata rrtnsl ves'cnan',the ilia mel responsibility to na'fY dee pan' mo/ 7/Q
code
reyuh, ch m t be met p issuance of a Cenrfin"a I
of p y. fFR'-
g1 0 Signature Applicant V Date
' Owur or eudwdzd Da
All roof coverings to be Class`B"or better
OFFICE