00050141 CITY OF CUPERTINO R� PERMITNf-OTL.
jUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: NLN J O
22 0 8 SANIIARYNO. APPLICATION
IOIN
SUBMITTAL DATE e C/t / �
NIC CON'TROLN
. 1111ONI.: 1 /OSS I7— QS � ❑ ��L5—
ARCHITECT/FNGINEEN BULDING PERMIT INFO
G `-0a1G24-' fp N
LICENSEDCONTRACTOR'SOECLARATION
OZ=p 1 hereby affirm than 1 am lieensedower pmosionr of C'hapar 9(Comtmming Job Description
w withllform7000)ofDivixion3o(me Boniness area Rmfrniom Code,aw mYlianae is
W s a m mu mee .na erten.
o y u Elmore clan I'S R
3 a Dnc Cwmwct
y
ARCHITECTS DECLARATION
xR s 1 unnd dersamy plans shall be used ss public tecarda
a'n e z
Licentious]Pmfessioral
OWNER-BUILDER DECLARATION
1 hereby anon that 1 am exempt from Ne Contractors License taw,for the
fF 0 following resson.(Section 703 1.5,Business and Professions Code:Any city m County
ocF which"mons a permit to commout,alter,improve,demolish,or repro any swdurc S FL Floor Area Valuation
5_ prior to its issuance,am requites the applicant for such permit w File a signed statement q'
that he is licemedpunuant to the pronnionsof the Convector.Liunsc Law(Chapter 9 �tf-" V
(commencingwith Smdon7000)of Division3ofthe Business and Professiom eoae)m pN Number Occupancy
WI he is rump,therefrom and the basis for the alleged cumption.Any violation of P Y Type
Section 7031.5 by any apphcam foea pemat subjects rhe applicant to a civil penalty of
not more than Five hundred dollars(3500).
I,as Owner ofthe,pro my,or myemployvawith wages atheir wile eampewtion. Required Inspections -
will do Ne work,and the s rmume is not intended or offered for We(Sm.7(314,Buurcu
.red Pmfmsiors Code:The Contractor's Liame law docs not apply to an owner of
Properly who Wohit or improves therwn,and who doesmot work himself or though
his own employees,provided that such impro musents tic not intended or offered for
ale.If,however,thc building or impovemem is sold within one year of campleGon,the
owntt-Wilder,will have tlrc When of proving that W did nm Wild in improve for pur-
poseofink.).
n I,m owner of lose property,sure exclusively contracting with licensed convenors to
construct she project(Sm.7014.Businoas and professium Cade:)The Convectors U.
cenu law does cost apply to wp
ntt of prony wW Wilde Imo mtMnon,and
who Contracts for such projects
ts with acono-xtw(a)licelicensedpurentuM w the Contrecrorl
License U.
❑lam<x sp d ec. .B&P f
Own
Date
RATION
:SCO Simy folloning
iherebynnrrunderconal re.fC.0 of Nefollowing drorim" tu: V
El IMve endide forbineCeri37M of she Labor
o6insuv for Workers Co of the
.tion,as provided(Pe mi Ss mon 3700 of she labor Cade,for the perfonneuce of the
work(or which will
Permit is issued.
I have and will ma.for Workch Cance Of the w Iltwra which
as rtquued by Bordon
my3700 of Wmthelabor Critic.for theperformanceC me oral work fm wbich Nispmnit is iswed.
My Workers Compensation Insurance C.end Policy numbn ase:
Cartier: PION FROM
CERTIFlC O OF EXEMPTION FROM WORKERS'
COMPENSATION N INSURANCE
(This action new nm becmnplaed ifNe pemdl in formic hundred dollen(3100)
or less.)
1 certify IT in the prformuncof Ne work for which his pamtit is issued.)shall
Wo employ any peon in any manner an,an in became-him'In the Workers'Compn-
titian laws of Califomie.Dame
Applicant
NOTICE TO APPLICANT:If.me,malting this Cef ificame of Exempaw,you should
WC.subjmt to the Worker's Co.,....provisions of the Isbor Cade,you mutt
f,,,T comply win,such Provisions on this pemtit shell W deferred rooked.
CONSTRUCTION LENDING AGENCY
O I hereby aTrtn that there iso CoriWCtion lending agency for the Perfonnwce of
Z the wmk for which this pcmtit is issued(Sm.3097,Civ.C.)
t:. lendrrs Name
LendersAddress
I certify don 1 have roof this application and able Chat the aWsC irrumation is
0. correct.I hi w Comply with Of City and County Otdirsarml and sue laws mlasing to
7 Z Wilding construction,and hereby inthotize representatives of this city W enter upon the
U 0 above-mcmianed prv,my for impsomm.purpoms.
W rC„ (We)agree to nave,indemnify and trop hamtleas be City of Cupertino against
0 (J liabilities,jodgmenU,<onte and expenaen which may in any wgaccmeagainsuaid City
^^ La7 in consequence of th meting of this permit.
'r S API•LIIT NDSANDWILI.0 PLYWI'I'l1ALLNpNA lIN1'
Z Sit f.GUL If
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n canvco I m Dad e I�7J�Lie t
HAZA WUS MATERI DISCLOSURE
WilltW applicant or fuwm Wilding occupant smnmhandle hazWoux material Re-roofs
Of
defined by the Cupertino Municipal Code,Chapter 9.12,cad me Health and Safety Type of Roof
Code,Section 15532007 YP
❑YCs
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
men
emit hewdous an conamiiants as defined by the Bay Arcs AB Qality Management installed. If a roof is installed without first obtaining an inspection
°in °'aYf9 ❑+l I agree to remove all new materials for inspection. Applicant
Ih.e mW ate hazudws maW
Cess regairements ander nape 6.95 ofaae Cal. understands and will comply with all non point source regulations.
fonds Health& ty Code,Smtiom 25.505,25533 and 25534.1 utamtuW that if the
Wil ' tl ve aretunt that it is my responsibility 'yore Occupant
r u I ormns me Ofa( Hpally
1 For Signature of Applicant Date
oozed ag t Date
All roof coverings to be Class"B"or better
OFFICE