00020185 r
CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
A
BUILDINCAU 17, �`'� ,L., SANITARY NO. APPLICATION SUBMITTAL DATI
�21
Z �ca_\S�' (fa,"n Ave-
OW ER S NAM
'NIC CONTNOLY
In trH c: 2 0 �0.4G / CA, 908 ❑
go / 6ULUING PERMT INFO
ARCHITE(r N 'INER
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LICENSED CONTRACnOR'SDECons of CDN
oSn 1herebyaRfmthe1unIkenseduttdcrpmviaionsofChapter9(commercing Job Description
P=C5an wiNSwion]000)ofDivision3of me Buainos aMPofesi m Care.aa myliameis ///��� �s a
�yuCQinfull force enc eB _ O it z. /ivl �j � /r��
Iaceruc 1J[.Y (�-f l `�, to
3 0 y Date Covtrznor —` �n////ff11
t u O g _ ARCHnFCT'S DEC ATIO / � ��a,a e
1 undenuM mY PIs^[shall be used upublic /(fes
aE4 licensed Pmfenimul
OWNER-BUILDER DECLARATION _
=='r 1 hereby aarm that 1 and exempt from the Contractor's License Law for ms
f s O following mason.(swim 7031.5.Business and Rof iom Cade:Any city or county
3 m which requires a permit to consbma,alcor.holumne,demon..Of repair my srmamm Sq. Ft. Floor Area Valuatioq,.r,
prim to inuus
ince,elan"sire,the applicant fa.mh pmmit to fileaaigned stacbmit
that he is licenua punosus to me provisions of rhe Cmma.rs Licenu law(CMprm 9 sw
(commeacing orb Section]000)oroiviaion 3ofthe Business and too..i...Cada)in APN Number T
mat he is exengt meewm aM be basis Tar the alleged example...Any violalm. ecuane! — P Y YPe
Section 7031.5 by any applicant fin a permit aubjacu Ju applicant m e civil penalty of
rot come mut rive hurdrcd dollars(5300).
❑I,now.a.fthepropeny,mmyempl.ymswimwagesumeirwiccompmu m. Required Inspections
willdomework,aMmes"ciumisnmintendedorofferedfms0c(Sa,7W.Bminess
W Professiam Code:TW Co..,.License taw dace Trot apply rn an owner M
property wed builds or impmves be or.as who does such wank himself or though
his own employer,provided brut such impmvemena an,not intended or offered for
We.If,however,he building or improvement is sold wiminarc yrarof mmplctim,be
owner-W ildcr will here be WAR.of proving that he did not Wild or improve fee pur-
poseof We.).
L as ower,of the,prapmy, exclusively protracting withlicensedm /
constrN
uct e project sin.7064
,Business dna professions Code)The Contracture Li- w}/
or.taw does act apply to an owns of property who pr
Wilda.1 innve rhaerm.and
whoeonmans for such projects wimrseco acmr(s)licensed punuau
no the ContrutWa
license law
.0
/
I rte exempt under Sm. .B h P C for this recon
Ower Data 0
WORKER'S COMPENSATION DECLARATION
1 hereby eRrm under paWly of perjury,one of the following declvauoo:
']I haveuW will mrinulna Cmifiote ofC.nsenl to self-insure(mworkersCompen-
tion,as provided for by Section 37M of the Labor Cade,for the performance of the
or for which this permit is issued.
have and will maintain Workers Compensation Insurance.in m9uired by Section
] of be laWr Cale./or me perf.rmeacc of me woh(or which bis permit is issued.
My Work< s Compensation In.Yzamc tern.and Polic nu :
Carrier; Policy No
CE ATE E FTION FROM WORKERS'
COMPENSATION INSURANCE
(This faction aMrrot be completed if the permit is forms,hundred dollen($IN)
Or lend
1 cenify that in the pedrurnarre.f the work fmwhich this permit is i...ad.I shall
na employ any pawn in any manna w v m became xmbject to the Windlass Courlo'
s tion Laws of California.Data
Apphourt
NONCE TO APPLICANT:If,after making this Certificate of Exemption you should
hm.me subject to the Workers Compeoatioo provisionn of me labor CMB,you must
forthwith comply with such provisions or this m.nit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
Q Q Ithereby affirm Jan there it.construction lending agency far be peff—ce Of
Z me work for which this permit is issued(Sec.3097,Civ,C.)
Larders Name
z _`> lender's Addreaa
!rd I cenlfy Jut 1 have read this application and sum that the above information is
I agree to comply with all city as county adirunees and sum laws relaing to
7 zcorrect.building Wromftion,and hereby amlionu repreunuJves of this city to enter upon be
C.7 C above-memioned propmY for inspection purposes.
W Eco ova)agree to save,indemnify as keep hefmlcss the City of Cupertino agtinst
C V liabilities,judgmerns,cmu as expenses whichmry in any way accrueagalnst said City
in emsegveace of the granting of this parmiC
[� APPLICANT UNDERSTANDS AND WI 1.1,COMPLY WITI I ALL NON-POINT
V z .SOURCE REGULATIONS.
Signature of ApplicanJConvectur Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store Or handle hazardous material Re-roofs
as rained by the Cupertino Municipal Cads.ChaPho 9.12.as the Heath and Safety Type of Roof
code,SectionE55321a)] YP
]Yen 1Ya
Will the applicant or future building occupant use equipmentmdevices which All roofs shall be inspected prior to any roofing material being
emit hazallom concomitants concnts as defined by me Bay Aro An QWlryManagementMgement installed. If a roof is Installed without first obtaining an inspection
Disala] I a ree to remove all new materials for inspection. Applicant
Call—❑Yen
I have the banrdoua materiala.Nuiremcnu maker Chapter 6,95 of the
His, &sd.IY Code.Sealom 25505, 533 and 2553a.1 mndenua that if the
din ms na cu can mnank than my sponsibili modify the occupant
uemm which m ] m pLwr m of a C ware M y.� -
�K1041W Signature of Applicant Date
Ow euthorizedagen � Dam
1All roof coverings to be Class`B"or better
OFFICE