00020175 CITY OF CUPERTINO , ' PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR,I'-NFORMAT,lON:' - �� a
BUILDING qADDRP_SS:
s 100 /) Nar1>)6k q� VJ/1TW 14��k& Qv� /W SANITARY NO. APPLICATION SUBMITTAL DATE
O .yx w LL �G E M(M) & ;0_" Nic CONTROL"
PH 6 . 2s5 -03// L�rD6(i /� t<(a.�{/./(e ICA-/ gs�s ❑
IF CHITECTI NGINEER /^QOV ^o ✓ y� � " BULDING PERMIT INPO '
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" - LICENSED CONTRACTOR'S DECLARATION
O :0 1 herby affirm Nm 1 em licensed under provisions of Cap"9(commeiaing Job Description -
t.,:�u, with Section]000Ill. to Ne Busimss and Profnsio C actor -cenun ��
a in BfrrceandeBept .n , 'Oleo h�eak� /�
Lipena.C Lic.N
ATS DECLARATION
lundunderstand my'les Wait bused aspublic
records
ai)S.
w a O O Utchand Profer"had
n tits OWNER-BUILDER DECLARATION
I hereby aRmt tat I am eaemp from We Coaramuser Liam law fee the
z d f011avin8 seaaro.(Section 7031.5.Businessland Profmion CCrk:Any city«county
i 3_ wbach"loansa permit m Construct.ills,imprors,demolW,or repair any emaprue alua•{u n
prim m
t0 ,ixsueoce,What equ
requires the Wherat for such pemrcdSq. FL Floor Area
ut to files sig
martenl
Nal a is littnud pennant to Ne provisions Cf the Contractors Liana law(CTaplu 9
(commencing with Section 7000)of Division 3 ofd"Business and Pmfemirn cork)« "PN
Na N T2&
b r Occu ane T e
W is eump therefromnd to sbasis f« Ca
We d1cged Campion.Any violation of /n P Y YP
Section]D3U by any app&ant f«a pemut subjects the applicanno a Civil penalty of 2 /
pt mart sten five hundred dollar(5500).
I.as owner of to partially,Ca my employees with wages in Walt sole croalmoatian, Required Inspections
will d0 We work,and e:The ma is trot intendns m,acted f«We lpply to an Busincas
property who
Code:The C er dramas License law Was era appy himself owns gh
his we who build,or improves rsuchn,end who dos arch vote dedcaor Waugh
his own however,
he provided the such i onto.told w aR not intended«ottercd for
sola If.howevcall low,We bur en a proving
is Cold did Outer oldyeaor improve foe to
pose, builrkr will ave Nc burden of proving Net he did nm Wild or improve for par- 11
roti of Wena
❑I,u over of the Scc.7 •,m Business
lay professional with:)The croacttr.U.
mntrvct to project(Sec.]D41,Buairem fed professional,who, Code:)The Crnu,arm. nil S,/lVf
ante law does not applyje an own«of property who bunds or impovas enteon.end
who contracts for each projaa with a ronbacmrfs)1'renaed pusumt to the COntrsstors
Liccnulaw.
El 1 am cxemp under Sep. .B h P C for Nis rtaaon
Owner Dae
WORKER'S COMPENSATION DECLARATION
=Yaw auby affirm under pmilty of'"jury roe of We frllmvin8 declared.:
ft,I ave nM will nuinain a Cenifcne ofCornenuh xlf-ivaum f«Worker,Campcn-
tion,as provided for by Section 3]00 of We tabor C«Is,for the pesf..of to
r which Nis permit is issued.
1 have and will maintain Workers Compensation Insurance,es required by Section
3]IIOrf Ne labor Cade,fm the efomtence ofthe work for which this permit is issued.
MCayWOrrkedal'1M atiygl_nsupggtt cacricrimil Policy �
Pot mU
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi,mctinn rand tent bccomphool ifthc pmol is forone hundretl dollen(S100)
or los.)
I certify that in to performmce of We work for which this senrut is issued,l shill
our employ any peon in any marcor m as m became,subject to We Workers'Compen-
sation law,of Caifomia Da¢
Applicant
NOTICE TO APPLICANT:1f,afar making this Ccnificaa of Ensued.,you Mould
become subject to the Workers Compensation provisions of the labor Code,you must
forthwith Comply with such provisions in this permit sill Ise deemed rooked.
CONSTRUCTION LENDING AGENCY
Q 0 Ihcrcby affirm that Vert is a comwNon lending agency far to Perfomwroc of -
Z to wok for which Was permit is isaud(Sec.3099,Civ,C.)
Fro Lender,Name
(� }_ Lenders Address
W 1 anify Net I have read Nis applicmar,and Woman...Nat Ne above Wontion is
Mt zcorrect.l agree to Comply with all city and County Ordinances and sue law,relating to
.7 z building crossrocumn.=it h"Soy authorise rtpeunativn of this city to enter upon We
U 0 alcove-mentioned patient for inspection purynes.
W E.. (We)since to save,indemnify and kap hamless the City of Collura against
�1 liabilities,judgments,cos;and expenses which may in any way accrue against mid City
} W in Comequcucc of Uteming of t n permit
APPLICANTUNDIi . I'ANUSA ')WII.I.C(IMPI.YWI'I'HAI.I.NONdgIN'I'
U Z SOURCE REG" NS.
Signature ofAWliclork9hoacto, / gDaa
HAZARDOUS MATERIALS DISCLOSURE
Will to applicant or future building occupant state«handle Installations material Re-roofs
as deEmd by the Cupertino Mnnidwl Code,Chapter 9.12,real la HW N and Safely Type of Roof
Chile.Satires 25532(m / YP
Oyer �N
Will We applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hanadous au amumunnu as defined by N<Bay Arca AG Quality Management installed. If a roof is Installed without first obtaining an inspection
Discin] I a vee to remove all new materials for inspection. Applicant
Over
ave«.dN hnad«nm te rcgnrcm aunder Gapa 695rfN Ga i- understands an will co ly with all non point source regulations.
fomla Hertm A Safety C eciions 25505,25533 end 25534.I understand Net if the /�
Fuilding does n«cwently emnmL Nnin is responsibility to notify Ne Coupon
of We ac'moo em who the Con prih asuance ofa Cenitic roof Opo cy.
Signature of Appfl&nr Date
Owner or authodacd age ate
All roof coverings to be Class`B"or better
OFFICE