01050147 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDI'l, DU Io� O 14V C� ��• PERM IO16 O'��
OW'NE 'S 19AMC: O R ��,{i�y�IW(�, • APPLICATION SUB DATE
S7—0/
PHONE: ` wSANITARY NO. CONTROL N(l.
U AHCIII I'ECI'/ENGINEER: `/•�//�{/I/I/J� ` —• BUILDING I'LMll'INPo
RO O J 131.I1G ELECT IERMU3 MliCll
Fly
yz ucBNSBD coNTancD3R's DecLnRnTlory Job Descrip on
z. — d n reby:allirn.Ih'1 am Ilcn,.wJ and', Pnrvlsinns of Chapter 9 temm�cncing .
�LF�w x'ithS um71 oUrviaonlufit" in neesanJ l'nlexmiuns Code.unJmylicena
a S , it ell lorcc m 'ci... l
C,z Is''Case
it Class Lic.N
uvi ARCHITECT'S DECublic a cind
F=O I undcamnd n,)Phan shall be usW as Public rtamds
CCE
w z •p Licensed PmRoional
a. a c1WNER-BUILDER DECLARATION
1 hereby affirm thm I nm exempt(roan the Contractor's License Law for the
Z a fallowing naso.beedi n 7031.5.Business and Professions Coale:Any city or county
IEC which 1 pennit wct alker.improve,denialish.or repairany structure
Ce Ce 3 m pr a t nw,m q Ih a.al t l - h pe ,t t I gn d.t cement
,,a,1 licensed amrsIt he p viDn c t n L I.C.(Chapmr9 Sy. Ft. Floor Area Valuation
Icununen in,win,Secant 7odo of DIs a,.mn 3 of the Baines•ul P-momm,Code)
or thm hu is CWcd,pi 1hemn) and lim bmsis for the alleged exemption.Any violualon
ofsccaioa70.3 shynity;Lpprcamfmaper,i,,I APN unit Oc pancy Type
of nal nmm firm live hundred dellmn 15500).
❑I,as owmr rel the Pmpeny.ar my employee,with wa ice as(heir sole compenswi m.
will do the work,and the limInme is not intended ur offered for sale(See.7043,
Business and 1'm@ssions Code:The Contmcmr's License Law docs n(,,apply In an Required Inspections
caner of propeny Who builds or improves thereon,and who doe,such work himself
or through his own employees.provided that such improvements an nut intended or
nffead for sale.If,however,the building or improvement is sold within one year of
Completion.the,,'Derr N.1Jer vill have the burden of proving that he did not build m
improve for purpose of ale).
❑1,as owner of the propeny,am exclusively Contracting;with licensed comremats to -
nsu err the project(Sec.70C4,Business and Profcsanns Cea l TheFINALED
Cantratm's
License L,w down am apply m an owner of property who builds or improves theme,,
and who contracts for such projects with a comeanarfs)Ilceowd pursuant to the
Coaraenr's license Law _ JUL 3 0 2002
❑1 nn,CWeanpa under See. .It N P C for this reason
I owner naata
WORKER'S COMPENSn'I]ON DI!CLARNI'ION BUILDING
I hCemelfrin under penally of jury one nl'Ihe tollowing deeladio I,:
❑ I have and will mainmin a Cenilicam n1Cnmant in wiGh's re far Worker's
Coanaenxution, as provided for by Section PW rel' the Labor Code, for the
peffommnce of the work for which this peril is issued.
❑1 bite u d will amiyylIsin Worker's Compensation Insurance.a<rtyuiml by Smion
374 Ih LaMm ywe,fo the performance of the work for Which this permit is
y 5'odc l Cnmpen own Insurance carrier
//and qpolicy
renumber am:
Cure'
CI?RTIFICA'[ON OF EXENIITIfIN PROM W'UHKE S'
COMPENSATION INSURANCE
11his well....need an,be completed if the permit is Iconic hundred dollars
I$10(h m less.)
1 eerlif,tbaa In the perdanwnee mf the work lirt winch anis peril is issued.1
xhull nal employ any pe'son in any ne ic,sit an m bcctnnu,abject m,the Wmrkcls'
Cnnarynsution Law,of Cdifomla IJue
APPIInana .
N U CU IT A9'LICANI''.If,after making this Canilicnlc ret lixcmpmnn,year shoald
became subject to the Wo,ker',Comlmnsouoa provision,of the labor Code.You anus
Q O fortm,IN entnply with such provision,or this permit.shall he banned revoked.
Z
E' CONSTRUCTION LENDI NG AGENCY
CC 1 hereby Which then is a conq (Sec. lending agency for IM1e performance
Lca he N liar whim this permit in iswcA(Sm.7(MJ7.Civ.C)
0. Q lender's Nunc
� UZ lender's AJJr[nz
0 1 sentry thin I have read this application and su¢thumbs above information as
F.. correct.1 agree to comply with all city and county oolinances and%lac laws rtdming
Q C.7 tlmbuildm,,unomctioa.and herein,authorize representatives of this city m enter upon
y W allo,I,.nWoljnrCd property f .peel p H
WC)agree tt)save,indemnify and keepM1 ss the City ofCupertino against
fqaladaic,I Jg u u e J Penn 'Ind, y In a l -y againstaid
V Ti C encu f II g 16,1 pill
W ,`J
' Ida AN'I'11NDERS \NL 'ANOWILLCOMI'LYWI'IHA .UNN�OINT Issued by: Date
A'1'10 Q
.,bnnlne mnpppeamoc..mmnnr —- Dm�\ Re-roofs
HAZARDOUS MATTER SDISCLOSURIi
Will die app0a,m..r fnmre lmilding, magme..r handle na>.mJ..ae n,amdal Type of Roof
as deleted by Um Capenino Municipal Code.Chapter 9.12,and the Health and Safety
Code. ❑Yes 2553$0)' pN9 .
All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future buildingoccupam use equipment or des'ices wnich If a roof is installed without first obtaining an inspection, I agree to remove
emit hatardom air canuminarts as defined by the Bay Area Air Quality Nfunage m nt
District., all new materials for inspection. Applicant understands and will comply with
. ❑res ONa all non-point source regulations.
I have read[tic hazardous material,requirements under Chapter 6.95 of the
C nnia llcala i k Salem Code.Sections 255115.25531 and 25.5.14.1 u,dersund that
chuild'mg Jae,not cu cnfly have a emma.that hie any resp.msibility to ratify the '
v1 a I,hit rc aircm nb which meq h Dred Prima a nu 'u f n CcnlEcme of
Y. 1 Signature of Applicant Date
mu r
All roof coverings to be Class ••B" or better
e m:mm..d.ed Igen Data
OFFICE