00020128 CITY OF CUPERTINO PERNIMNO.
' 000ao
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: f
BUILDINGAODRESS:
wk SANITARY NO. !A'P�PLIC�ATION�SUB,MI/T'TpApsL�D�A]
OWN I,YI�ryt/y��A/'• <//+S1 ✓� RFL' �J
' WC CONTROL.
VIIONC: 2 V/J ❑
AIiC111T[CDE'.INE13H BUIDING PERMIT INTO
�C
v LICENSED CONTRACTOR'S DECLARATION
OO i: 1 hereby antra this 1 am licensed unto provisions of Chewer 9(commcrcing I��- ^ Job Description
e m wiNSection700Wriviion3oflW Businem and f riomC .Wmyloarceis
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41�i LL y ��3�!��f �— k GOrmecmr
F LL O¢ I an CHr1ECTS DECLARA U
I undenuM my plans shall be used as Public rccwda
LfcaaaW Pmfessiosul
LL LL OWNER-BUILDER DECLARATION
t Y r I Wreby affirm that l son ea<mpl from the Contractor'.License Lew fm IW
dF o following rcaaan.(Section 7031.5,Business and Pmfnsions CWe:Any city or county
i C wb,,"Nim a psom to cmtslmct.alter,improve.demolish,or repair any suramne S Ft. Floor Area Valuation
3" prim to its iuuan«,ilse rc9uircN
s <appficant fmsuch purist.Fist..aiBmml.tater q'
that he is licensed Wmuant to the provisions of the Conn¢lor's License law(Chapter 9
(commencing win Section]000)or Division 3 of the Busuesv and Prores.ion.Code)or ApN Number Occupancy Type
Wt be is<unryt naerrom W the basis far Ne allew sa<mptien.Any violation of
Senbn 70313 by any applicant her a permit subjects the appficanuo a civil Penalty of
m mote then five hunGeG dollen(35001
C)1,as owner of lM pmfawt,or my employ«s with wages u their vole compeumbern, Required Inspections
usigglithe,work.and Nmwmurc isnot uamded oroRuad for use(S..7W'Business
onvacmr'v Li«nse law d«s rot apply to an ow«r o/
b it who don such wok himself w Juoupf
y« n t' dad m IT real for
vaQ
ow
I o c .the as
owrcr-Wilder wt have vi t t e pur- /
p owner N
atem'tui to
n 1Ne a Sec. inn :1TW Comm�msLL /« 1 f Curnmeand
< [OnlrCtof6
rNisionon v O
e e N
t 1 beroV affirm under pen ty ofV ere cyg Ip_or, len
❑leave eW will meimilna Cenihc.m of Consenuu self-1111 II�r ompen-
ntion.as psevldal for by Swum 3700 of the labor Cud.,for the Penfem once or the
woBt for which this pemN i.issued.
O I luae aha will Maintain Wtalun s Campemation Imurerce.u tau owl by Section
3]V of the tabor Cale,for he performance critic work for which this permit is isned.
My Wortlr'>C e' er Vetcerrierend Policynuolbet�rs:A21�/1�
Carrier. L1 !% Policy No:W/jiFJTJ�J 7�
CERTIFICATE OF EKEMPDON FROM WORKERS'
COMPENSATION INSURANCE
Tfhisractinine der.bacmPleo epe 'Tia torose huMr<ddollars($100)
m I..)
IccnifYlMlnth Pafo fthe for hTh Nivpcmdt is iuved.l shill
era employ any Penns nY s < w py LI e 'rkees'Compen-
satirar awsof Culifomi. f�
Applicant
NOTICE TO APPLIC f r g is[nificee of En neva oo.You should
hecone wbiect to tha W. es C mutatio s provisions of the labor Code,your mon —�4
feMwith comply with wch ponscamv or this permit ahall be domed mvokrd.
CONSTRUCTION LENDING AGENCY V
Q p Ihercbya lmNUNemisaconlmcuonler ingagemyfmm pcdm eof
z the work for which Nis permit if issued(Sec.7077,Civ.CI '
Iandat'a Nanta FEB 16
C >_ lana<rIcarry ZOOO
07 1 Unify sew 1 have read this a and!Ilion aha awe that tee above information is
0. Z carrot.l agree to comely with ill city nut county mdwrcof W slue laws r mon
to .
.7 Z build' comwction,enJ hmchy euNoris rcpreunwivn of this city to toter upon the
C.1 above miunet pmpeny for inspection puryoaes,
ire F.
We
agr« ova.iMenmirY and knp banaleas ere City or C-Peniao.gain-
rJ liabiliu ',judgnaMt cm"an w ch rruYinmY wry accrue agilnn said City
in cone u<rcco Brun permi.
wFi 4 APYhI( N'1'U• D R.'.NIJS A. IWII .C(IMPLY WITII. LL NONdKIINT
SOURCI II 1 iA' INS.
U L
stgmw a Dn
a IAA DOUS MATERIALS DISCLOSURC
Will Ne ymlt vert Orfuturc Wilding«cupam strne or handle huWous meeriil Re-r001s
u defirad by the Cupnnirw Municipl Code.ChapMr 9.12,W on H<ilth and Safety Type of Roof
Cede.section ss532(en yP
❑Yes C3 No
Will the applicant or future Wilding occupant use eicipne^m''o�r devices which All ro fs sha be inspected prior to any roofing material being
emit I waAws ser conumiaows,aredefined by Ne Bay Arca AirQ dVManagement install d. If a oof ism lled without first obtaining an inspection
Distinct] I agree o ree
I e materials for inspection. Applicant
01 ❑Yes ❑NoI�damateriabhapter695.o1aCili. unders odsl ply with all non point sour regulations.
s forrua Heel safety od s 2]53 aha 25s36.1 odenland that if the
building d«s veem 1,Nau spon.ibili ono' dm«.upas
of the tryuirc u A n sl isms primM las of Cr t'cem Ihcu
Signature App nt Date IF
Ow«r ore 1
Date All roof coverings to be Class"B" or better
OFFICE
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