00040115 CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ®o 0 410 1 6
BUILDINGADDRCSS: Z"TERM,o^wit1 �,
NYIVIr../S i{i,V �y 6ANITARY NO.NL5� APPLICATION SUBMITTAL DATE
- ND�tE.ST�AA I `i
E NAME: a IVINV#�L&ICAa940 NCONTROLp
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DNr.: 44
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wOO BULDIHG PERM1IIT INFO
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s-Nz LICENSED CONTRACroR'SDECLARATION JobDescri Don
[._o I hsmby aRrm than 1 am licensed under provisions of Chapter 9(commencing p
hFw witgtatim 70001ofDivirun3of NeBusiness essio usittnse is IJ�/�� �� '
<y Y� in Lful
l forte and cR<n
Lienee CI v Lic.N
Dale l� CAnttacbr �� MCI E� V I^ �l4
wor hop Pe )67 INf - - pN
a scanedRofeaional RV
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OWNER-BUILDER DECLARATION
t Z 4 1 hereby affirm that l am exempt from she Comnamfs License Law for to
cI=oer following moron.(Section 703 L5,Busimss and Professions Cuda:Any city or aunty
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which customs a Permit m cavum, mo
also•improve,delish•m repair any amnio Sq. Ft. Floor Area Valuat,
rtq prioo its issuance,Oso rtquims the applicant for such Pemni 10 file a signsdmtimem q•
that he is licensed patentor to the provisions of she contraerols License Law,(Chapter 9
(commencing wish Section 70W)of Division 3 of the Business and Prof.W.Codc)m umber Occupancy T e
that he m eaempr therefrom W she basis foe the allsgcd exemption.Any violation of SI p y p
Section 703 L5 by any applicant for a permit subjects she applicant to a civil pevlry of L R
not mom Bun Eve handled dollars(SSW).
❑Laahwrcrkrndtheseny,amyompt%eedoimwagdforWeirrolccmnpemwnt. Required Inspections
will profs work,and the structure is not intended or offered for We(Sec.Wan.Business
and professions Code:The vis dome's Lineman Ida docs nal apply to owrcr,of
property who builds or improves domem,improvements and who dao such work himself of dough
his own emDloyaa,movidnd the such ntisW are not intended m lRe .for
ownef,however,are Wil ding rimprovement issold didcme Yenr improve
for tc
owner-W staler will have to When of proving(het he did nm Wild err iminove for par-
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as rwrcr of the propep,.B exclusively&wy inertial..g wish licensednntramm b
comsat the es WE (Sec.ora.,Bmlllaa tad inertial...Code:)The Contractor.thers .Li- /
who law dnaortapply banower.ofImperil,mirs wed Willa Or topics"Cocos,and '
who cmtrwls for ouch Proltau wit aconunoNe)licensed parsram to the Crnhaabta O
ucense law. O
1 am exempt under Sec. .B&P C for this rwan
Owner Date
WORKER'S COMPENSATION DECLARATION
1 booby alflrtn under Parody of palmy one of IW fdlmving declarations:
I have and will mainuln a Cenificare of Conwnmo self-imum for Workers Comprn-
salion,as provided for by Station 37W of the Labor Code,for the petfomurce of she
work for which this Permit is issued.
❑I have and will maintain Wakes Compenuoion Im urarcs,as«guyed by Section
3700of We Labor Code,for
d�rc�pr(cA�ormMe�ae of the work for which this Permit h imu ed.
My W IFI TE OF WI iY Narit y
Cu e
was
CLRTr'ICA E%EM i N FROM E R
COMPENSATIONINSURANCE
(This Fasim rad era W completed if Ne permit is frrorc hundad dalton(51110)
or len.)
I eenify Wal In IM performance of to work for which this pemut is Issued,l dull
not employ any penom j;I dy marine n I t b Wcm Orknes Compen-
sation law f O'o ere {■`�yRe/]
APWiemt IM .g eco1111
NOTICE ICA IL e r m 1 eco purer,You should
fecome subject y to Worhefs Compeer hon pmvisiom of to meed i Cade.You rant
forthwith comply with such mrvlairna or this Per^it shall W domed invoked.
CONSTRUCTION LENDING AGENCY
O I hereby affirm don them is a conduction lending agency for the performance of
z t
C4
c work for which this permit is issued(Sec.3097.Civ.C.)
F. Unit,,x Name
Lander',Address
Gk7I ratify that 1 have read Wis applica kine and Adele tat the above information is
IL zcommagree.I ae to comply wit aland l city county cadiato
nisi sure lows relating
Z Wilding consumetion.and hereby authorize rtpenmatives of IN'city to enrer upon the
I..) above-mentioned property for inspection purposes.
(We)aline to ave.indemnify and kacp hauleaa the City of Cupertino agalmt
U liabilisies,judgmcom costs and expenses which may in any way accrue against said City
W in comequcae of to granting of tis permit.
— y AI'I'LICAMI'UNDERS'l ANDS AND WI LL COM PLY WI I I I ALL NON.Potsrr
V z SOURCE RVGUlAT1ONS.
r Sigatumol'ApplicanthConuutor IyaR Jac ►9/y7bwv 4r
HAZARDOUS MATERIALS DISCLOSURE
Will lhe.pptitern.,utum Wading necupams rare or handle haaudous material Re-roofs
as defined by the Cupctino Municipal Code,Chapter 9.12,amp the HWth and Salary T e of Roof
Codes Station 8532(07 /` yp
❑Yes vNr
Will to applicant or future Wilding mcupml use e9nipment or&vias which All roofs shall be inspected prior to any roofing material being
mh hn,alms.ir cmuminanh as it ed by the Bay Area Air Qn.1"managemcm installed. If a roof is installed without first obtaining an inspection
unit, .0/r/' I agree to remove all new materials for inspection. Applicant
❑Yes g
Ihum tidthtm,prints"ummmtsunder Chapter 6.95ofthe,Gah- understands and will comply with all non point source regulations.
forms Health&Safety Code,Sections 8505,25533 and 8534.1 undersuM that if do
Wilding dam,.cummly mw a wool,Wt is is my rmponsiNiiry b naify tc occupmt
t5cc,umWm.wh,ch m .rmiasu.d.Cmificate ofOa my.
a Signature of Applicant Date
w neat e t ate
41 NW
All roof coverings to be Class"B"or better -
OFFICE