00050031 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:- dD
BUILDING ADDRESS: om�
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_ JJJ/ '< SANI'rARYNO. APPLICATION SUBMITTAL DATE
OWNE AMI (/O 'l o �( J
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739 - 3 , 45023
ARCH ITEC'I'/HNG INEHR BIJLDING YIiRMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
1 hereby aRrm Nat I w II«vaed under provisions of Chapter 9(commeveing Job Description
with Scaion7M)ofDivision 3 oftie Business and PrMevions Cade.and mY license msin Poll force andc�«Me� 3� �eN 2-1 -moo.
x Da¢ 1 y 71 Convacror ,�Q.
I..:,p g ARCHITECTS DECLARATION 7
� 1 undenranW my plw shall be tired m public rtc«da /I � (p7 ))
w z e OT �V
p.n. LicenaeR
d ofcnionel r Q
OWNER BUILDER DECLARATION �� ,z., 3 t_71.
1 fsf of
s_z i hereby am.mum 11.exempt from the Conran LicenseLicenseLaw fm the `[`
f D following Leman.(Section-ro31.5.BusinessW Prof moor code;
de:MY city or county
x which require,Siam m cnww0.allimprove. .,ord.vlscrose
pmmit.i.wn«e.ahm experts ran Whereof for uh permit mfile
a signed a.emenl
S Ft Floor Area oValu�tion
Nn nu
he is licensed ptmant to Lee provisions of the Conva.ors Linc law(Chapter 9 NP
(commencing with Section 1000)of Division 3 of the Busier and Professions Code)or p Number Occupancy e
W .t he is e. apl thm erefroand the Emir for the alleged exemption.Any violation a _ P Y YP
Section 7031.5 by any applicant for a penNs subjecta the applicant to a civil penalty Of
Qmot mn them Eve hurled dollars(5500).
1,as..of the propeny.m....players wits wages m lbefr sole cmnpematim. Required Inspections
wall do the work.and du sbuc,.is are moreded moff.ed for We(Sao.1014,Business
and Profession,Code:The Contractor's License law does rot apply to an owner a
propeny who builds or improves Nersmm,and who docs such work herself or Ih em ji
his own employees,provided that such improvements aR nm intended or offered for
We.If,however tW Wilding or improvement la sold wimim one yearnfcomDletion,the
ver-build.will have me When ofproving Inas M did nm build m improve for p -
pose W owner
I,m ower of da,SmpenY,.B"elusivelyesand cono-ncdng with IJcemeC Cormorant
i-
cemtmmIseDrone.pplyoan Business andrty who Wiontslds
Code:)Tha Cpntracmrs rad
cent law dons for
apply m an with
a os property once seills rs improves mertov.and
who comfort.for ouch protect.with a conlnmor(s)licence pursuant to the Contractors -
License Law,
I am eaempl under Sec. .B R P C roe this,won
Ower Data
WORKER'S COMPENSATION DECLARATION /
I heIs y.I I.under penalty of perjury exam on
e of the(Oloving declamations: /
I have and will malnuin a Ceni0cam of Consent m ciGinsurefor Work.'s Compcn- J1/
m,as provided fee by Section 37W of the Labor Cade,for the performance of me
' hich this per Wt is issued.
W will..main Werner.Companmtion Insurance.as requited by Section Vaal
�.„dn LeWr Code,for the pcdomuee of IW work fm ahicE Otis permit u iwmN. V
Myrrier. 6a�anffim I�umcc cyd.and PolicYatnks -secs J(/`/
carrier.��/Q.Ti 7-a"^/l PoI¢YNo:L1C ,, / /O
CERTIFICATE OF EKEMFrION FROM WORKERS'
COMPENSATION INSURANCE
fELi,OwOM,mmm rad he completed itthc permit is faronehundrW dollars HH W)
Or I.A
1 ecody that in the perrormmtce ofine work for which this permit is imued.I shall
not employ any pemma in any manner M Is to become subject to the Workna'Compen-
ction laws of California.Dan
Applicant
NOTICE TO APPLICANT:IL after makmg this Certificate of Exemption,you should
become,subject to the Workers Compenmrio t provisions of the Labor Code,you must
fonhwim comply with such previsions or this permit dull W de m A revoked.
Z CONSTRUCTION LENDING AGENCY
Q 0 Ibenby off.,that them is a construction lending agency for the performance of
wZ.1 Ne work for which this pammit is Issued(Sec.3191,Civ,Q
Ungar,Name
[(s 7 Lenders Address
Sr7E I candy that 1 have mull this application and sate then me above information is
L cowl.I ague to comply wins dl city and county ordinances and sun Laws relating to
Wilding construction.and hereby authorize reprecntativu of this city in enter upon use
V Q eEovrmemioed property,for inspection purposes.
L'. E,w (We)agree to rave.indemnify and k.p harmless On City of Cupertino egaimt
V Iinbilui.,judgment..crate and e.penca which may in any way mcmeagalnv said City
in consequence of me granting or this pemtit.
t� C6 APPLICANT UNDF.RSFANDS AND WILL COMPLY WIH ALL NON-POINT
V Z souucx cv s.
ArL� 0
Signature of Appl' ctm Dan 0
��
HAZARXZAR DOUS MATERIALS DISCLOSURE
Will by the
rfuran Wal Coe,Chapter
vomer handle haeardousmmenal Re-roots
m defined by the Cupertino Municipal Cade,,CM1apter 9.12,oral the HedN and Safety Type of Roof
Code.Section❑yX5532601a�� YP
Will the applicant or future Wilding occupant use equipmenr or devices which All roofs shall be inspected prior to any roofing material being
emit hamming.air cunumiuns as defined by me Bay Ana Ah Ouliry tManagement installed. If a roof is Installed without first obtaining an inspection
Di.trieo
❑Ycr y.l� I agree to remove all new materials for inspection. Applicant
n ve esdthe n.ma fors artggrtm teunder Chapter 6.95o the moi- un erstands nd will comply with all non point source regulations.
( forma Halm R Smay code,Satiw 25505.25533 and 25534.I undenund that if the - /��
1/ buildingdmn cumrtnllyy veecna don mtnmY rtspominilirymnmify the«cupavt L/
of the nt I Ins nhn rimmiSsuaae ofaC.tif fO cupency.
� � aL- 00 Signature Applicant Dale -
OwnerormuntruMergrut Den
All roof coverings to be Class"B"or better
OFFICE