00020120 CITY'OF CUFERTINO PERMITNo
BUILDING DIVISION PERMIT CONTRACTORdNFORMATION: 0(30'2- 10 / 2LQ
BUILDING ADDRESS: /` 1_
16' _rOtAt�tV,f EIU V`T '�Q(fi lll�f,Ia�1t�5ANITARYNO. APPLICATIONSUBMITTAL DALE
OWNER'SN ME: n 2
3 6a�U(fin�C II MC CONTROLp
RIoN
ARCHITECI'/ENGINEER I IGo�Sua/ ' �+� l '� V V BULDING PERMIT INFO
Qoo
°�Z u 6 Da
w
LICENSED CONTRACTOR'S DECLARATION
Inembr,fm,nthat,lRan Rranea under Dm.;dom of Chapter 9(<nmm<n<ing Job Description
0__r°i
yonO id 6U in full for, T000)of DivisionJof the Business am Peofevim0ittnLic.N ) s Cade,aMmY littnse is �4�.
;may Dnc G
ARCHS DEC
t a O ITECTS DECLARATION \..it,��}<(J• w
yon , 1 undenuM my Plans¢h,il W used OR publi<recads
w a°0. licrosW Professional
X y OWNER-BUILDER DECLARATION
C Z< 1 hereby affirm that I am exempt from Ne Contractors License Law for the
z r°o following recon.(Section M3 1.5.Business and Professions,Code:Any city m Wooly
which uins a pemma
ut crstruaalar,ar,improve,demolish,m repair any morcum
i ty3 Prior tons ionum,4.W,Wras the.,ficam f.mit'rost,to filt.si'mol.tatmoud Sq. Ft. Floor Area Valuation
Net he is licensed pursuant to Ne provisions of Ne ContraaaM1 Liccn.raw(Chapter 9
(commencing with Section 7000)of Division Sof Ne Business thul Professiotu Code)or APN umber Occupancy Type
dot he is eunryt therefrom W Me basis for the alleged<ssmpdern.Any,violation of -Z-Z,
P Y YP
Section 7031.5 by any applicant for a permit mbjects Ne applicant to a civil Penalty,of &2(0 ,0 O G L a
not moa Nan five hundred dollars(5500).
I.as ownerarNepropcnr,mmr<mployaawiNw,ges.Nedaolecompeauuan. Required Inspections
willdo Ne work,and Ne structure is our inanaedoroRened fm We(Sec.yoke,Business
and Pofessiona Cade:The Contractor',License law does non apply to an awn,a
property who builds or improves thereon,soul who does such work himself or through
his awn employee.Me pmviaed thv such improvemeaa thin non inaMed a alfend For U S'N E S S
.le.If.hawemr,rh buil dingorimprovement isoldwithin aneildori prove for da
erbuilder will have Nc burden of Proving Nat he did oat Wild m improve for pur
P.of
❑1,an owner of the property..m conclusively cmtraung wish:)¢need cantractoss to
Construct Med project(Sec.Tula,..enters and Professions Code:)M Contractors oLi-
,mm
}} V 1 p ��N
c a law ams not apply to ts owner of Property who sed p or improves Coreon,and F{ rt�',T
whocontractsfor such projau Within[onlrutodsllicensed pursuant Ne Contractors '
Liana law. �;
SE
1 am exempt unser 5,. .B A P C for Nis rtsson
Dwner Dona ; . �UIRE�
WORKER'S COMPENSATION DECLARATION t
1 Wreby affirm send,penalty of perjury oro of Ua fallowing d,landoM:
1 have eZ1 will maimun a Cenifcaa of Conunuo self-inmm for Worker's Compere-
union,m provided fm by Smoon 3700 of da labor Cade,for the perfomume of Ne
work for which Nis permit is iasmd.
1 have and will maintain Worker'.Compensation Inaufamt.u required by Satian
3700.f6.LaW,Code,for Ne pcdu mu tt of the work for which this permit is issued.
My Wmk<1s Compensation Monsoon canner and Policy number,¢:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' C' ED
COMPENSATION INSURANCE ■
(This melon reel.bemmpleted Writs permit is fmone hundred dollar(SIM)
Or let..) JUN
K�[ Imnify rhino in the pertomunee ofNewmk(mwhich Nispemth is issued,Ishell 0 I 2001
employ any person in my onus, s t subject to Ne Workers'Compcm '! L
.tion laws of fmnia,Dam ��I �
Applicants
I
NOTICE TO APPLICANT:If,afarmnsati this visin so of Exemption,you,y should UILDI�
femme h emn,m Ne Wah<usim Compensation or do, D.I,shall
of de Labor Cade,you mon
fmthwiN comply wish such provisions or this permit shall be damrd¢voted. !!p
CONSTRUCTION LENDING AGENCY
G 0 Ihereby affirm dm Nem is a comwedon lending agency for Ne performance of 000e 9 /
Z the work for which Of,pcmul is issued(Sec.3U9T.Civ.C.) G 1 r�..
F—, Landers Name L a��
ai lento,Address V
1 ceNfy Net I have read this epphcaliod Nd state dot da above infomofion is /,)
d coarct.I agme to comply with ail city sed county ordloances and Rule laws aiming to /1
7 bWve-mentioned
and hereby•umon uupscunutivea of Nis city menar upon the `/// a
above mentioned propene for erep,ban lost,ha.
(We).gra b sive indcmnifY ant kap harmless the City of Cupertino a8ainst
V incononquece,of
connng of this Permit.
m,yinavy wry aaNeagainst.id City
2W n con.aq NT N the granting of Nis permit.
.�+
in
UNUIiRSTANUS AND WILL COMPLY WI ALL NONIroINI' >
V � SOURCIi
rF.GUTATIONS.
- --�
S..nat..of Appbc ntlConmuf.r — I Dau
HAZARDOUS MATERIALS DISCLOS
k.
Will Me applicant or fumy Wilding occupant woe or handle huWoua material Re-roofs
M defined by the Cupertino Municipal Cade,Chapter 9.1&ant the Health and Safety Type of Roof '
Code S,Oon 25532ul? YP
❑Yd ONO
Will Nc applicant or future Wilding occupant use equipment or d<Vices which All roofs shall be inspected prior to any roofing material being
mit haasol.,air eonuminenu as dented by led Bay Arca AG Quality Management installed. If a roof is installed without first obtaining an inspection
"mule°li, I a ree to remove all new materials for inspection. Applicant
❑Yes ❑No
I .emdNeb.vraWamaterialaroarimmentaunderChap,695ofNeGR)i- un lerrstands and will comply with all non point source regulations.
famla Welding does o Safety Cade.Savors 2.5505,n,My and 235Ja.I to..if,
Nu if am
Forma Health
non Safety Coe. nthn,Me,d$M.ismY ands,m.bilfty5yl.I mnaifymhehat if a
arch met nicht tbema as v+saaucP of.ecoircum of acupsmy.
Signature of Applicant Date
'21,Ph n:W.on, Daa
All roof coverings to be Class"B"or better
OFFICE