00030222 CITY OF CUPERTINO PA1RNO'
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: CO
RUILDINGADDRESS: G/ `� SANIPARY NO. APPLICATION5UBM=AL DAT
OWNER'S NAME: q�O ���� /V BOLO
J G �/�,� NIC �/COM'I'RIOLp
PHONL: c"-e� 5 y23 �V / JL717 �O �V
ARCHITECT/ENGINEEEER 5'v��3 BULDING PERMIT INFO
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U
r�'6'� LICENSED CONTRACTOR'S DECLARATION
z0 OHC L hereby aRrm Ina 1 am Comber licemed under provisions of Coer 9(commencing Job Description
_n C m wide Section 7")ofDiviim.3of erre Business it Prefenm ioCode,and my hcrnae is
¢z W 6
Daclass Li
in full force and effect.
O 0 class a ♦ -
E6 Dem Cnnfracwr
^ uncle m sseal S DEC TION
y I �O�L
i'a�� licros.d Pro(eui
_ OWNER-BUILDER DECLARATION
t=s Phmeby affirm that 1 an exempt from the Cations Cage:License Lew for the
i- following reason. panni on cora dra t,gmx aM Prof ions h,orMy city m musty '
m wmmmgail«.pesosmcnusty.ap licntfram,deormsi errminor anyaaamue Sq. Ft. Floor Area Valuation0 V
prier fo its iamenee,alsot�uirts Neapplicant for such pamdtafleasigneA messes �J
the Mislicensed S.Ii.nwNebavuionsoftheeBusi mLiceof< siw&Ct )9 d001
that he
canwides«Don mirth basisnr shedcpdexempton,Any
of APN Number Occu ane T e
That l e is essmb therefrom W W suis for she alleged exemption.Any uolatlon of b P Y YP
Section ohm by any dred doll fn a pemdt subjma Ise applicanno a civil penalty of 3i6- 7 — QC/
wim mote Nen f vc huMmM dollen(55001.
Laawesof Nebapeny,ar is tante mwishwager utheymole W.Bue mu Required Inspections
will do do tusk,sad dee smrnurt isnot.Lamm m Law
do Im matepply 1014.Dusinea
and eine ons Code:The over dommo Liana Law saes era apply s lf owner of
his o nY who Wilds m improves deacon,aid who dam such work himself m through
him own employeese podded r improvements sum ambos sold within
am m inardM m oRertd far
salem.Wildm will[rva se Windf pvmssnotsw id cion Wild
impyeas omldiorshe
o r-Wilder will have dee Wrdcn of proving Nat ere did nn Wild or improve for pn-
pose of sale.).
C]1,as awaer of she property,an exclusively convecting wish licensed con moors w
,hammer to pmlen(S«.1041,Business aM Professions Cade:)TW Conuacmrs Li-
came Law dm not apply to an owner of property who builds at improves Nneon,and
who comrcls formula projects wish a coefmcror(s)licensed pursuant to the Conametn's
License Law,
❑tan exempt erne .D ,iwfar thus on
On, ORKF.R PDNSATION D 'IARATION C
1 hereby aitrn undo pmahy of perjury ore of the following decluatiam. 3//�/
1haveaMwillm nWnaCmificaaof C..s ll.elf-insumforwo esCompen-
Wks,as provided fm by Section 3100 of the Labor Code,for the perfomunm of she
work for which this permit is issued.
❑1 have and will maintain Wnhets Compensation Interstice,in required by Section
3100of she L vor Code.for the performam of she weak For which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number m:
Carrico Policy No:
CERTIFICATE OF EXE [MON FROM WORKERS'
COMPENSATION INSURANCE Il
(This section mad ned h.omllmal ifthe permit is fmone hundred dollars(SIW) 1'+-- MAR 312000
or leu.l j
Loy my Froin in my onnemso as
Wcomeork for whichsho perthe Wmsses'Cosmad. shall
rot employ any person in eDY manner mo ns m become sabj«t w the workers'campers- -�
sation taws of California.Dam -,
Apphlato
NOTICE TO APPLICANT:If,after making this cmdficem of Exemption,you should
hm mom sabjem to Ne wmwa Compenurion provisions or fire Labs Cade,you must
forthwith comply not such provisions or this .it shall W deemed revoked,
CONSTRUCTION LENDING AGENCY
Q O Ihereby affirm don Mo.isa.omnuctian lending agency for perfmmance of
z.
the work for which this notion u issued(Sec.3091,Civ.C.)
rvr Lenders Name
CZ 7 Under',Address
Ls7 I cmiry,that 1 have tend tis application art area deal the above itdamution is
0. Acone..I agree to comply wish W city,sod county me nam,and sera laws relating m
.7 Z building construction.mad Maby wdwri exposemaiveaoffhis city to amerupon she
V O me sans ioned property for inspection purposes.
W Fs (WO agree to save,indemnify and keep harmless the City of Cupertino against
U liabihties,jodgerems cuts and expenses which may in any way secrue Maar,said City
in consequence of the grunting of this permit,
F+
A. APPLICANI'UNDIiRS'TANUS AN 1)WILLC d P1Y W1'IIIALL NON-POINT
U A. SOIL C' IULAI'In
Sigvfua of Applic Co era Dam
ARDOUS MATERIALS DISCLOSURE
Will the rep C1.1 fmuse building occupant ane or handle hazadous mamriil Re-roofs
as defined by the Cupertino Municipal Cade.Chapter 9.12.and she Health and Safety Type of Roof
Cade,Section 25532(a)t YP
❑Yes cn<_
Will Nc applicmt or future Wilding mcupad use equipment or&vice,which All roofs shall be inspected prior to any roofing material being
I hvardow ah contaminsnts as defined by Ne Bay Area Ah Quality Management installed. If a roof is installed without first obtaining an inspection
iminr
❑Yes EX. I a ree to remove all new materials for inspection. Applicant
I have real dee hamstring materials requirements under Chapter 695 of the Cali- un erstands and will comply with all non point source regulations.
fmw Hcalth&Safety Cade.Sections 25505,u533 sed 2553x.1 sidershod shat if she
building does nor ancon at iM' ismomibiloy lY the pats
of n t w f g�9dypaap
�I/ o/ Signature of Applicant Date
Owner or auto zed aged Dass
All roof coverings to be Class"B"or better
OFFICE