00030068CITY OF CUPERTINO PERMUNO.
_ BVILDING DIVISION PERMIT CONTRACTOR INFORMATION: (0(:9031004,g
ILDINGADDRESS:
SANRARY NO. �ICATIONgUBMTTAL/AS3$ Not-y1sllN^�-0-0-
OWNIiRsM
I.r ���,r U / I I� l N/C CONTROLp
b
ARCHITECT/ENGINEER IIULDING PERMIT INFO
O '
Yp
6j
LICENSED CONTRACTOR'S DECLARATION
z O y z 1 hereby aRnn Net I am licensed under Provisions of Chapter 9 (commencing Job Description
F1_� wiMSatim17OMy fDMsi.n3of rhe Borimasarul Prommi... Cadc,andmyliceam,a
in full farce and effect
License Class Lic.g
% 3 i r Dam Convacwr
C LL O ¢ ARCHTFECI'S DECLARATION
J 1 utWersuM my plans "I be used as Public rewnls
.cp.
n. a Uccmed ProfeuiorW
t- z r I hereby .(Seth out 1 am exempt from the ConLiam: Law (o the
i x O followin8 .. (Section 703 1.5, Burins.road Profession, Profession,ion, iom GCa de: wry city Or wunry
uF $ which requves a Permit m comwm, alter, impove, demolish, m repair any I.C. S Ft. Floor A a valU IOn
3 _ pnm,o its ismin...alm requires Me applicant fm such permi 1. filcesigncriamemem q' ^^ }��.e� ./ /IJ/��/'a�[�
Nat he is licensed Pursuant to Ne provisions of the Commwra License Law (Chapter 9 e./O g(/ • / Z/&
(commencing with Section 7M) of Division3 of Me Business and Professions Cedm)m Num�b/E - Occu ancyT e
Wt he is exempt therefrom and oro Nor Por the alleged saempadim. Any violation of / nt P T� YP
Shemin 7031.5 by any appWant for a permit subjats doth applicant to a civil penalty of .i/ �.
m them then Bve hundred dollars (5300).
Lasawmr of tiro property. or my<mplgcea with w.guurheir ante cmnpcwtion. Required Inspections
willdoth<work,e t ser lumistrotintendedmoffere fm We(Sm.70a4.Buwhers
and Pror<Woaa Code: The Conm«'tori License Lew dams not apply to an owser of
poppy who Wilds or Improve. Merton, aM who does such wart himself as, through
his own employ«:, provided that such improammm art not wended or offered for
sale. If, however, the Wilding m improvement is sold within one year of complulon, oro Sawowner-Wilder will have Me burden of proving that he did not Wild or improve for pur-
pose of sale.).
t] I, as owtxr of Ne property, am exclusively contracting with licensed contractors to ('1
consuuat the project (ger. 7W, Business aM Prefessiom Code:) The Conumwr's Li. , O
cars¢ law docs her, apply,. an owner of property wed Wilds m improves oaermn, end
wWchrumtr Fmitchpojecuwiffiaconuacto0s)licenAp ntwthe Conn toes
U. law. I ILL'
❑ lam<aeatpunde, .BAPC' Mr (assort V MAR 0 8 2000
sorsa rebY one
OAATIO
N
aarmaK
pnal,Y o! p jury aero o! rose following declantiom: p
❑Ih.ve.mwillmeintunaCnificauof Cons ttowl6inmm(or Worker.Compn- By
astion, as provided fm by Section 3700 of Ne LOW, Code, for the perfomuna of the
work for which this permit is issued.
t] 1 have soul will maintain Workers Compensation Insurance. u honored by Section
3700of oat LeWr Cade. for the prfortnsone of the wart for which this permit is limited.
My Workers Compemetion Inumattee earner and Policy number soh:
Carver. Policy No.:
CERTDTCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed ilium ped t h, Future buMred dol ler ($I00)
in less.)
I certify the, in the Ndundrawenf the work forwhich thio prom is issued, ) shall
not employ any Person in my manner so as w became subject to the worlame' Compn-
anion laws dCalifornia Dree
Applicant
NCFOCE TO APPLICANT: If, afar making this Certificate of Exemption, you shmdd
became subject to the Workers Compensation mvi, ihn, of the labor Cade. yon mum
forthwith comply with such provisions or this Permit shill be deemed revoked.
CONSfRUC7nON LENDING AGENCY
O 0 I hereby affirm that there is. camtmetion lending agency ran the promunce of
u ti Ne workm
for which this petia 30
t is issued (Sec. Civ. C.)
F. Lenders Name
a > lenders Address.
WI certify Me,1 have rad Mia application and sone Net the above information, is
0. z corers I agree to comply with all city and county Ordinances W sum laws moring to
Wilding construction. and hereby mohonime representatives of this city to cover upon trim
f..) aWvcmcntiooed papery fm imla co.. purpose..
4. F (We) agree in save, indemnify and kap hafmlew the City of Cupertino against
O U liabilities. judgmam, cmu and espenues which may in my way scans against said City
y W in comequmme, of Me Inning of Mrs perm,.
is APPLICANT UNDF.RSTANUSANU WILLCU PI,Y WITIIALL NUN-��
0. S(3URCEN'rU w.RS-FA. V
Uz N/ 3
oF.fA,ficmaTfbmamo,1 I I Date
HAlARDOUS MATERIALS DISCLOSURE
Will IN applicant Or future Wilding occupant store or handle hazWous mamnal Re -roofs
m defined by the Cuprm. Munk ilial Code. Chafes, 9.11, atd Me Health and Sare,y Type Of Roof
Cade. Section 15531(.)7 yP
❑Yes ONO
Will the applicant or future Wilding occupant use equipment Or devices which All roofs shall be inspected prior to any roofing material being
<Whevrou.ale canumnmrsasefned
, didby Me Bay Am. AG Quality Management installed. If a roof is installed without first obtaining an inspection
Dia"l°Yes ❑ No I agree to remove all new materials for inspection. Applicant
L Wve reed the h.audao.m.tenal. regairementa eller Chapter 6.95 of Me,Gali-
un erstands and will comply with all non point source regulations.
fomu Health A, safety Code, Sections 2;M. Z533 and 25534. I understand Met if IN
Wilding dos no muerte chane it I,m rts"ability.. ythe occa m,
a(Mc refs. meth eofaCmihce I upeay,
Signature of Applicant Date
OwKraa z agent Data
All roof coverings to be Class "B" or better
OFFICE