00070063 CITY OF CUPERTINO
MAI-A)ING DlvtsnENI 'ART PERMIT CONTRACTOR INFORMATION: mol
BUILDINGA .... PERMITNO,
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OWNER'S A . APPLICA'I'I ONSUB DATE
PERT
ONL SANITARY NO. CONTROL NO.
na Z ARCH1111CI'li?NGINECR,, BUILDING PITRMI'I'INFO
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5 m LICENSFD CONTRACIOR'S DECLARATION
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(hereby alimn(tont Lmit licensed under prevision,of Charter 9(commencing DEMO Job Description
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-wt_J wiin full foreland effect.Division TM1e Busincns and Profezaon<Codc.and my
o YSJ iv in full fume unci dfea.
z It O.am m Glossa Li'.a
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:O i s, Ilam S DEC YAr
3 0-vl—i NtChallbe se DECLARATION
O g unJnvnnJ Iny plans shall M used m public mmN,
to
g O O Licensed Prom,ional
o LL OWNER-BUILDER DITCLARATION
to 1 hereby alYnn that 1 am exempt from the Contractor's License Law for the
hollowing reason.(Section 7031.5,Business and Pmfes,ioes Code:Any city or county
Seo wtich requires:I Perrutf I I.alter.improve.demoliolo,or mil.t cturc'
ronto t Isar N ptfl' ant( -u hp wall 'g Lt tmnlnl
cp
.am for,Im Ip aamt for pmoi,uilliflu,c lel xL La,(Chprer9 Sq. Ft. Floor Area Jaw
Icon,mimml with S,,l 70 go of Ilnvlsinn 3 of the Business earl Projessons Calc)
or that he is esempt membom and the Isom,for The alleged cxcmplinn.Any violation _
of Section 7031.5 by any applicant for a pem+it subjects the applicant its a civil penalty
.trial more than five hundred dollars D500). A Occupancy Type
[IT.as owner of the property,lir my employees with wages as(heir%ole compemation.
w111 do the work,;,not he smwoom i, I,,,intended or offered for nine(Sce.7044. J
Rastnese and Profer%iorrs Coda:The Contractor's Licnnw Law doer not amply to art qts a ❑. Ctl BS
+wncror property Who hul,N or impro c,Tbacnn,and who ducx wah xonk uro,ll
I,,Through his own cn mloy,v,provided That u,h improvements Imre not Intended or ,
offered for eine.If,however,the building or innprom, or is.roll waloin one Yva,1-1
completion.the owner-builder will haae the hoiden of pmving Thai he did not build sir
improve for purpose of sale.).
❑I a f the plufarl I.eseltelwell adowfirl dhlicensed"Ituraccom,m
conjotruct the project(S1 (44Business anti Professions GJ ) The Contractor's
lJoeme Law thov, I rppl,t w t r of pointy h build intpooes(h ere to,
rd ooh I' T. Too Inch""j.... itb I Coninector(s)lice I Pursuant at The -
CemrJTr-I' 1'x
❑I ant exempt under See .11&PC Ibnhis ma to
0.not Date
WORKER'S COMPENSATION DECLARATION
1 hereby afOmn under penalty of perjury one of the fallowing dedambons:
❑ 1 have olid will n+inwin I Ccnific:el of Consent Ins wl6inrum hr Worker's -
Compemanum, us ao,d,d tar by Swit ped )1 the Luhnr Calc, for the
pef ormame If me stark for whI,h his Iremdl is issued.
❑1 Time and will maintain Worker's Compensation Insurance.a%required by Section
3700 of the Labor Code.for the performance of the work in,,xhich his permit i,
sued My Worker,Compemmion Insurance carrier and Policy numher am:
Carrier; Perot,Na:
C2R'DPK'A'DON OI'E%17MIll ION PROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed it Ilie permit is liar one hundred dollars
IS Hp)or lest.)
1 certify that in the performance of the work for which thin permit is issued,I
shall not employ any Persson in any manner so Its to become subject To the Workers
Comla'mmion haws of California.Date
'C'plicaa'
NOTICE 90 AMILICAN'1':11:aftcrrnal Nle Ccrtlfmafn al Iixc npTlo r,you,hnaIII
IN, tote suhjen lir the W..kcr'e Cnmpomudu Ipnrrvixi.....al the Labor Code.Ynu moot
Q 0 fonhwilh comply with such provisions or This permit shall be dermad revoked.
F (Zi CONSTRUCTION LENDING AGENCY
? 1 hereby u(fnn that there it a commuction lending agency for The performance
of the xa,k for which This pencil is issued Ise,3097,Cie C.)
1 Q Leader's Nmne
D J Lcndcr's Address
V Q I certify That 1 have read do,appllaadon and 11-11 dnnhe nbrvl intbrmmion I%
las F.r cnor,, I agree to onnnp1,x'ib all city rud county nrdinaece,and limn law,relating
O U To buildingconnm,cllm0and bemnyllmhortm rcp+eumathes of City It,enter apr+n
the above-mentioned property for im,velmn puha
F ped, (We)agree to rave.indemnify and keep harmless the City of Cupertino againo
(n liabilities.Judgments,costs and expenses wbdt may in any way accrue against said
U Z. CITY in comcgmnce of The granting of Nis p,rdit. /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: (.- <--- Date 1--/2t--
SOURCE REGULATIONS,
Signanreof Applicant/Conuanor - Dare Re-roofs
IMARDOUS MAI URIALS DISCLOSURE
Will the apPhemn o,Total building acupant%tom or handle l amrdou,n1-mrial Type of Roof
a,defined by The Cupertino Municipal Code,Chapter 9.12.and The Health and Safety.
Cala. clu 2553211-)7
D ❑No
All roofs shall be inspected prior to any roofing material being installed.
Will mbeapphlrtm+lormum buBtfrngoIcalnnfale mpapmmrl"IdeviIr'"I"m If roof is installed without first obtaining an inspection. I agree to remove
nniI hvnNoor atr cool; t rmms m'ddincd by The Bay Arca Air Vnnullly Mamgemclu
L'shoee all new materials for inspection. Applicant understands and will comply with
EI Yes 0N all non-point source regulations.
I have read the hamrdm%materials requirements under Chapter 6.95 of the
California Health&Safety Code.Sections 25505.25533 toad 25534.I order smand that
if The building docs not cumatly have a tenant.That it is my imp....hi lily ,t notify The
occupant of The m,pimmmns which mum be Incl Prior to iwoug"of n Ceoi ieste of
OCC1'me1Cy Signature of Applicant _ Date
Owner-stn u,h.,I,cd Ingeri Dan I
All roof coverings to be Class "B" or better