00030135 CITY OF CUPERTINO PEANUT NO. _
BUILDING DIVISION PERMIT CONTRACTOR"INFORMATJON:- 00 ()'30 13 5 -
BUILDING ADDRESS: av 'f&� zadIttl- I/ � f/�� SANITARYNO. APPLICA10I �A�L,DATE
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ARCHITEC fENGINHER BOLDING PERMIT INTO'
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Fv i LICENSED CONTRACTOR'S DECLARATION
Z O v. I hereby aRrm thu 1 am limused underpmviiwns of Chapter 9(mmmercivg Job Description
F:C w withsectice7Wo)or Division of eBusimar and Rofeviam Code.and mY limina is
wa ;n full force and eR«t..�.. ;-e Z /[�fn/// ///�y//� �r
o V Ucen9C C�2f1i?ZZ�v
'a,as / /G 'P
t sh LL y Daa Contucmr /
t u,O ARCHITECTS DECLARATION
v� I undemwb my plana shall be u 1 u Publi<recmd.
ce
u.n z Licensed Rofeaaloml
c u� OWNER-BUILDER DECLARATION
N Z a 1 beeby.fess that 1 am exempt ft=she Comeacmrs License Law For the
7== foilowng reason.(S«uon]031.5.Busui and Profwiom Cade:Any city a ormodY
i3 m whim rtvuim.a pc.I,m Towson,alar,improve.drtrolim,Or put my.twcnue Sy. Ft. Floor Area Valuation
priato its issuance.also rt9Nres the applicant for such permit rile a signed auamm e
Nat he it licewed pmavantmNe provisions of NC Coneanors Licente Law lChaper9 � v'O
don
be is exempt
dbu firms al0l ter basis fee Orth,Budaexenedon.An,
A.Im.Of A N Number Occupancy Type
Nn he is earmpl Nrrtfmm and or burs for be Wcged eaemant to Any violation of q /P �, X10�f
Section them by any applicant for a permit the applicant a cavil penalty of J/T/!/q U /
wit prose Nen five hundd dollar y employees
Luown«ar the pestruc,amyempayecsw;thwageaas their compewtiw, Required Inspections
will do Ne work,acme: structure is net inundmse Lawrdfor formic aa,Business
and arty wZ u Code:The ws,,th teart and al saw alas not apply tone owner of
his ow.who builds or improve,.ueon,and who doer a wmk himself nmolthrough
for
his own rmployecs,provided Nat such improvements sold studio,
art nwt iyaMN a oRrd for
sale.If.however.the building or improvement pros
m it sold within one year r improve
for da
rr-bNld<r will have thr burden of provin6 that he did not build m improve fa per,
pmeof Wes. /
C]1.as mom of the propene am exclusively c...acung with limmed co...m
came La the mojen apply
]aa,Hotoowner
of and uy wh i burons Code:)The Contrwtm's U.
and Q/
come law dao ON apply je ts owner ea property who builds or impmvee Contractors uW
whatemse L,cufor such pwjau with.cwuactor(sl licemed punuwt u the Covaactoh 0
Creams law.
1 am exempt under S«. .B k P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1herebyaRrmunder pendty re Of Conoraofdmrallmdng WoracesCo
1 Mve and will mainWn a CeniOcate of Cowem m Wf-inwm for Wohers Comp<m
cation,a provided fro by Section 3]00 of the 4bor Cade,fm the pMomarca of the
V 4fw whim this permit is otter.
1 haveand willodi,for
Wnhcrr Campensmoneir for whites oxIthi,per by Section
3]OOof Ne Labor Code,lm the performarcc of the wort for which Nis permit u issued
My Wo ,CylpSp��Ipeania end PolieY nsynnJyesuM
Canis: ��/ 4 !/ Pobc No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissuctionn«dnot becorephood ifdnc permit it faronehurdiuldi lsrs(SIM)
or Iris.)
1 minify that in the performance of the work for which this pumnot is Daum,I.hall
net employ my prnon in my menxr as as to became subject to the Wortrn'Compen.
action Laws of Cdiforda.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Croifeste of Exemption,you should
lice.subject to the Workers Compemetion provisions of the Labor Code,you muor
forthwith comply with such provisions or this permit shall nd drrmcd revoked.
CONSTRUCTION LENDING AGENCY
Q I brushy affirm that there is a commucuon lending agency for the peAanm«e of
Ne..,it for which this permit is issued(Sec.3097,Civ,C.)
Lundre,Name
Lenders Address
WI certify no 1 base read this application and xWe ft,the above information is
96 A correct 1 ague to comply with ell city and county modmo crs and sus laws on a,mg m
Z building conswction.and hereby amhmiae¢praenntives of this city to enter upon the
C.) 0 above.marm;md pmleny for inelastic.purposm.
far F., (We)ague to save.indemnify and kap hatmles,the City of Cupertino against
O () hnhiliues,judgmrnts,coosim as n swhich may in any war accme.guns mid City
�. W ;n comenuc«r of the granum this permit.
F API'I.ICANTU 'DERST )S AND WILL COMPLY WITH ALI.NON.IOINT
U Z. SOURCE RF RI a
S;gaanraufAppli am nscta
RDOUS MATERIALS DISCLOSURE
Will theapplicanr or future Wilding occupant store or handle haa.tdous material Re-roofs
as defined by the Cupcnino Munot, I Code,Chapter 9.12,asd the Health and Safety Type of Roof
Core,S«turn 05]z(.)' YP
[I Yoes[IYes phrmtarfawab ;IdNg«rnpmtase9alassm,ordmcr.which All roofs shall be inspected prior to any roofing material being
it MvNou,air ramiso imntx ex defined by the Be,Asa Ab Quality Mwgcment installed. If a roof is Installed without first obtaining an inspection
I.. [ hJ,L^t I agree to remove all new materials for inspection. Applicant
[]Ye'
I Mveaad the hawduus matedilt requirtmenu uMu Qupter695 of the Cali-
understands and will comply with all non point source regulations.
fom;a health Iesafety Code,SaOont 25 O5,8533 end 23530.1 undrtsund Net if the !�
building domme currently luveau Nat it is my itspomibilitywmtify Neoccupant J
aft nyuvctrcna which st nen prig to;uwrcc ofsCmrfcuc�yf c
s Signature of App t Date
Orono or authotlaed age O
All roof coverings to be Class"B"or better
OFFICE