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00030044 CITY OF CUPERTINO PHRMrr NO BUILDING DIVISION PERMIT CONTRACTOR-INFORMATION- BUILDING ADDRESS: T c fr I(,�~7 f<� (,(e (((�,QQsf SANRARYNO. APPLICATIONNSStU�BMITTAL DAT( GW'NIiR'S N L'li: T" �` �] �C OL F Zz 0 z s ,` NIC 'CONTROLN PHONC' 13z S SAn _:Vose C'A ARC(III'I?CT/ENGINIiER BULL I'13RMIT INFO -S9�S U a oNLrmButIDCONTRACTORS derpDECLARATION JobDescri tion z0 z_p 1 ion? china Nu 1 3 licensed undss prornions of Code. 9 my liccneing p with Section]0W)ofDivision3ofthe Business end P.ofessioas Cade,and mylkameis C�xWf-5LL ca Lini�unllaefoCrclee and eR«I. LigU COn10cmrNDBIC ARCH 'S DECLARATION RTIONO< 1un laR - 5/+y/O / shall a ussd v public rcc«ds G L nca al _w / OWNER-BUILDER DECLARATION c••/ C Z a I hartby aRmr Nal i un exempt from Ne Comractors License Lew for the E z o following reason.(Section 7031.5.Business and Profassian.Code:Any city re county winch«quire a permit m cmmwm,altar,improve,demolish.re repair any'fracture Sq' Ft. Floor Area 7V.11 uat ieg 0 prim to its issuance,also rtquires the applicant fmsoch permit in Elc a signed emcocir that he is licensed pursuant the provisions of the Con ramoex License Lew(Chapter 9 (ionfintRucka with Sectimi 7M).f Division 3 of the Brain.and lifirfartion,Coce)or ppNNumber Occas Wt be is exempt dre rrrom and the basis fee e alleged exemption.Any violation of p �^� Occupancy Type Section]031.3 by any applicant for a proven udstwta the applicant 90•civil angry or 3kr/ © � 0V Ejt mom Nut five hundred dollen(S500). LesowncsaftheprapenY.Omyemployee.withwage.asthebao[etompenafion, - Required Inspections will do the work rued Na svuchre,i,not insnn sedoroRemd for We(Sec.7060.Business and DvfeWam Code:The Convumr's License law dons set apply to an owner w pmpany who Wilda of improves Merton.end who don such wort himself or NrcugM1 his own employeese provided NM such nnum ti mmm Ort na intended r oRartd for ole.If,however,the hoildie bin en a prmant timid within one yeas of completion,the ownenbuile).will have Nc burden of pmvin6 that he did not build m improve for p«- priesdingl 1.s owner of the Sec.7 ,em exclusively aivrly con ximsg with licensed Cconvenors i- cense at the project(Sec.o an Basions rod Professions Cudr:i The Convectors tad Li- cense law does not apply to ls owner a or progeny who builds or improves Nc«om and w who contracts f«such Prolan with econvacmrts)Licensed purswnuo Ne CanvectMs licenu law. I am<zempt under Svc. .B A P C for this such Owner Date V O WORKER'S COMPENSATION DECLARATION O I hereby ill man under penalty of perjury one of the following for declarations: 1have pro will maintaineCion 37m of the LRm u1GInmRehe WorkeraCompan- vtion,as provided fpeSection 3700 of the Labor Code,for(M1e peAomunce of the work for which tillsmaintain permit is woad. ❑1 have end will maintain Workers C"Bon core w re f r which h required by Section 3700of the taint case,for the pcHarm or Ne w«kr«wni<n rids permit is ia49W. _.- MyWorkc ryppeykgiia wwran« 'er and Policy Q(/Q E7 f' Gnicr. Policy No.: T D rel CERTIFICATE OF EXEMPTION FROSITWORKERl' COMPENSATION INSURANCE (This s«tium asset nes becomFlerW iflM pemul is foro«hundred dollars nRX) I.1, O p 000 1 ,l mks..) 1rJ MAR O UU I certify dust in the pedonnemeofthe work for which this permit is issued,I shall not employ my .on in any manner ao as to become mbjecr torte Wo-kenCompen- Orion Laws of CrlifmoR.Data Applicant t NOTICE TO APPLICANT:If,after making this Cenificare of Exemption,You should By--�--- he<ome ser ora,m tic Workers Coma or this provisions of di Leben Code,. forthwith comply with such ptovleiom or this permit shall be deemed invoked. CONSTRUCTION LENDING AGENCY Q Q I hereby arm Nes there i......tmNon[ending aganey for Re porbi ce of the wink for which this permit is Issued(Sec.3097,Civ.C.) Undies Name Landers Address Lti 1 unify,that 1 have rend Nis application and sale that the above infomrurn.is d Co...I agree to comply with NI city end county insinuates and ROM laws Relating ro D Z building construction,and hereby authodu representatives of this city to enter upon the U C) above-mentioned property for Inspection purposes. IL E. (We)agnea to save,indemnify and k«p frontiers the City of Cupertino against Q U hubdiicajudgmem,coward eaPe•res which may in any way eccme against said Cry y W in cone « she granting of th s permit. A- APPI. TO )ERSTANDS AND WILLCOMPLY Willi ALLNON POINT � S( '17 A'1'IONS. / t App ixem Connachn Dan JO t- J-9�/10A is—)CC, HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant score in handle haeadour marmal Re-roofs RR denncd by IN,Cupertino Municipal Cada.couple,9.12,and the Hrath and Safety Type of Roof Case.Sectio,2553z(q] YP ❑Yes 03 No Will the applicant or future Wilding occupant use equipment err devices which All roofs shall be inspected prior to any roofing material being l hawdous air contaminants as defined by the Bay Arca Air Quality Management installed. If a roof is installed without first obtaining an inspection m t7 I agree to remove all new materials for inspection. Applicant . m, aOYR. IPJ No g Anr� mthwa mastic.rtyui«mann Order Chapter 695 of the Cali- he ali_ understands and will comply with all non point source regulations. ode.SeW«ss 25505.25533 and 25534.1 utdeirs net Nat if they sawn.in.,Nm it is my ospomibiliry to nearly the occvWnt martxmat pt;uta u.r.nee ar.cenirnre nro«npaneySignature of ApplicantDate nt Data All roof coverings to be Class"B"or better OFFICE