00020056 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: �OO
BUILDINGADDRESS: {.I///wyT�vyf I��}j''f�g?/� /}(t'''yr l
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AWEER IfULDING PERMIT INFO
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F j va,i LICENSED CONTRACTOR'S DECLARATION
zo '- Il�rcbyafrrmwll.mlkeawednmerp�„dmaaorch.pler9rcmmneneing Job Description
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H w with Sxtion]OOo)ofDivisionJofth Busiauatd Profudou CRsde,ud mylic e
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In 73 /r/ � N�l/r /C Q/�/�f���✓�/�✓
C License CJpu Lic.M
ouIt.G Date IL1/� Conwcmr
ARCHITECTS DECLARATION
ON
understood my plain shall h used as public eecalds
y E:. ucenea Roreuiow
y I-a f Oat I am exempt
DEMRADON
etwun
F Z a 1 hereby n(Snot that i am aempl from the Cosm.,Co License law fm Ili
Wa,F following mann.(Scion]o L5,B.Witt,
ro nve.pinade iii Code:Any city ti mumy.
Wa Fj whim repnw.permh to enmweh amc,i applicant forsu deermit t nr m signed atmmmm Sq. Ft. Floor Area V%ion
pnor to ma t vWOfor such Permit to fileasigad.utemem -7ja V
thatmisclamed purswnt 7000)of Diaiom of theeBuanons and
LawfClupn9
(commencing with Secften an0)of Division tof he. elf it euavd ProfA,vi Codd of APN Number Occupancy Type
But he is exempt Nnrefrom and Ne buffs for bi tl the exemption Any violation Of
Section 7031.3 by any applicant fora permit mbjaH the appliranuo a civil penalty of
rot mole Nen five hundred dollen 155001.
❑L.sowark.nddamny,ormrempleym.withwagouNehao:. 044,Boatia, quit d Inspections
will do Nework,ands: o Com;.notimeMed moffend s salepply town,wnera
and Pefenioa Cade:The Conus mobs License taw chum not apply s if owner of
his o ny who build.or impmvu Nunn,uta who doss such work dad of i through
his own employees.Wilding
d Nat such mentis old w tie nm intended a oRered for
We.If,however,Ili building ser improvement Proving
is sold within we yetor of.Mvesion,the
+.-builder will neve Nc burden of proving Net he did not build o,improve for Pur-
of sale.).
(D 1,
T,u owner of the S..704 em exclusively.nd coo oWmes with:lcehe Cconnacmn - /
On.Law
project,ply]oH.Busimeu nope-y wh Wi Cade:)Th Conaaclols nd
cense law don nuupply to an Dever m mcmets who sed I or nottuvn Neon.nW
who cso Law.far ouch projecu witha conmrecmtld licensed pursuam m me Canmactot. O
Cllne law.
I em exempt ander Sec. .B k P C for this canon
Own” Dem
WORKER'S COMPENSATION DECLARATION
1 hereby.!firm under penalty of perjury one of the following decluatiom:
1 have end will minimm aCenificade of Conant In self-mmie for Workers Compen-
sation,as provi&d for by Section 3700 of the labor Cade,for the Peformaac of the
V
0,which this pemdl is issued.
have tial will mdnuin Workers Compensation Imuiaae.as re polled by Salon
J]00of de labor Code,for the performuRe of Bu work for which this Femtit la issued.
My Worker's vuti Insu +Iris and Poliry n ye_
e.me�here lase `Sr�niafle Poliry Nn.: Y. 1[a�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbisaectiunmind Trot becompieted if Ne permit is forone hunAW ddlan(5100)
or les..)
1 cenify that in the performance of the work fm which this permit is bound.I sbdl
not employ..y person;.any manner m m m become aubjm 1.the Wuhan'Compcn-
ution laws of Cdifomia.Due
Applicant
NOTICE TO APPLICANT:IL cher making this CeniOate of E.cmpEon,you I evold
become subject m the Wmkei'a Compensation pmvhioa of the labor Coda,you must
foMwiN comply with such provisions or his permit ahell h dremed revoked.
CONSTRUCTION LENDING AGENCY
0 I lereby ulfinh that them is a comvucti nt lerding agency f"Ron IK---O of
r y Nc wink for which this .it is sued(So..3099.Civ.C.)
Undies Name
7 Inoders Address
W ^n 1 certify slit 1 have mil Nia application ape tine thin the above iNomutia is
mrtet.I agree to comply with dl city and county ardiances W Rum laws minting m
Z building construction,and hereby aotho e,rcprcsenutivm of this6tym namu.pon the
V aW".nuan u mal Poyeny for;apection purposes,
(We)ogre in save,indemnify snd k"p humlesa me City of eupeni m against
Q t.7 lodelines,jWSmentscmuandaspen..which may in any wry acme against said City
�., ;4 is comequeae of Ili gmming of this pamtit.
t" 91. APPLICANTUNDERSI'A )SAND WI .COMPLY WITH ALLNON-PoIN'r
U Z SOURCE REGUTATIONS 7- 111106
Signature ul Applicant tn"or a Dale .V1
HAlARDOUS MATERIALS DISCLOSURE
\Yll theappheanl9r future Golding occupanlamrcor boodle
harallous material Re-roofs
u defined by the Cupertino Munici al Code.Chapter 9.13,ab the Health,nd Safety T e Of Roof
Codc,Section 335R1d? yp
OYes
ME the applicantox,!seam building occupant use agn;pmcat or devices which All roofs shall be inspected prior to any roofing material being
it bvribus air canlamiant %defined by lh Ana Ali AAli Quality Mingement installed. If a roof is Installed withoutfirst obtaining an inspection
iamtic° saI agree to remove all new materials for inspection. Applicant
El yes
IMve mad the hewdaul materia.mNiremenuunder Chap"6.95 of de Cvi. understands and will comply with all non point source regulations.
(
forms Health&Safety Code.Section 35505,25533 and]5534.1 undersuM that if the
building doesnd emmndy have.toms. ' ;s my reipondbiloy m notify the occupmt J
Of tho myuhcmenma wd�1 em poor m I....of a Ccnilicme M y cy. ,
! 214/On Signature of Applicant Date
(tear or euNoiizW t Ic
All roof coverings to be Class"B"or better
OFFICE