00040076 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACTOR INFiORM)AB'ION::,� lE�N
BUILDING ADDRCSS: / /wOW/ ` �a_
SANITARY NO. APPLICATION SUBMTITAL DATE
/09� be wie & P ti
/� —,Z_pp
OWNS "NA a ,e) . (3ok # S NIC CONTROL#
10
1A&P.
D' : -/27 M"t1lia 93133
ARCHITEC E-1,GINEER �� // BULDING'PERMIT1NI
10
LICENSED
l
aZ�
v LICENSED CONTRACTOR'S DECLARATION
O85 0 1 heabY affiw Nn 1 em licensed undo Provisions.f Chapter 9(commercing Job Descript\
F,v,,r u with Section7")ofDivision3oftheBusincasadPofnsiomCu myli«nae is ``//
K Y z 4 in full fact W effect.
DOW
w 3 tae'.H Dale understand _ �`-(1✓
r LL O RCxrf a usual
uud DEC
ConwcmrLARATI
5 1understandW understand my Plans shall as public roads
C Liecred Professional
OWNER-BUBAER DECLARATION
Fir 1 hereby an.dual 1 am exempt from the Contractors License Law for the
7=c following ressaws 'Section Co.7031.5.Budow,v and Pmfevio.s Cade:Any city a county
m wid m
n 3 which"uha gwa,alter,improve,dernoliah,or repairww
any sce ' Valuation
pri.nrui
.itsi.....ce.alsoroes lMapplicant for such penultm file.u'red statemmeSq. FL Floor Area
,to be is licensed pursuant to Ne provisions of dr ConuanMs Li«rase law(Chager9
(cmmncncingwi Sauon7OW)ofNvision3ofNeBmineua feuiomCde)a ant N tuber occupancy
Wt he is eaemq therefrom and the beefs for alleged!e allegsaemptimt.Any eialalion of P Y Type
Section 7031.5 by any appficmn for a perm t subjects thee applicant a civil penalty of aJ �
pI more than five hundred dollars($500).
Larnwnerartnegapersy.armyempiny«.wimw,gm..meir.al.eompem.dan. Required Inspections
will do the,work,and the sructure is tut inadd a offered for We(Sao.704,4,Bosircss
and Professions Code:The Corona-'-Li«rase law does nor apply to an owner a 5
property,who builds m improves Neswn,and who does such work himself or tlwugh
his own employees,govidd that such imgovemenu tae non indeed m offend for
sale.IL h.wmer,thc building an,imgoverrcnt is sold within..Ynr.f completion,the -
owner-Wilder,will have the Widen of proving that M did no Wild or improve fm For-
poscofsele.).
1,sa owmr of dr proper,aot eaclusivcly contracting wish licensed contractors to
consnpa the project(Ser.IOW,B..of,ad PiOr,wins,
siom Code:)Thr Con ere.n. rad
cense law on f nut apply je an owner of property who Wilds rs improves thereon,and
who rse Low's for such projects with acontrator(q licenad pursuant m the Conwdore
Liccnu law.
❑1 am<aemq under Ser. .B b.P C for this renin O
owns Date
WORKER'S COMPENSATION DECLARATION
1 bertby aRrtn under penalty of perjury use or dr following declantims:
I have and will maintain a Certificate of Cotucnt to self-insure fa Wo eacomgn-
...son,as provided for by Sado.3700 of Ne Labor Coda,for the crfurnuncc of the
work for which this person is issued.
❑1 have and will mainuin Wohcra Compensation Wuraore.ss"ohned by Section
37M.fthe 1,11ita,Code,to,the Pcxannmreofdr,work for wlricbthia gourd anumuld.
My Wurkc i arrecunm and Policy.
Carriee Policy No.:
CERTIFICATE OF RKEMPIION FROM WORKERS'
COMPENSATION INSURANCE
(nix action need not W completed if tha Fiction is Tao«hundre l dollars(SLW)
de Ices.)
I certify that in the perfor c of the wmk for which this perosl is issued,l shall
not employ any para..In any manna eco as 1.home a*-i to tha W'akcri Comgn-
sation laws of Califomia.Data
Applicant
NODCE TO APPLICANT:If,art«making this Certificate of E.emgion,you should
hews subjah to dr worked.Compensation provision of the labor code,you must
foMwith cm.ply with such q.vili...Or this gwit shall W domed revoked.
CONSTRUCTION LENDING AGENCY
Q Q l hereby alBhm that then,is a constmetion lending agency fm INCpdao^a^ce of
,Z r Ne wok for which this permit is issued(Sce.3097.Civ.C.)
(~" 4 lender's Neme
�i > tenders Addreu
Lp: E I cnnify that I cave rend this applicallon and sate that the aW Vc irif.t.n Is
0. correct.I ay«to Comply with all city and county atdlmnces and auu laws relating to
�D Z building construction.and hereby autbmite tcgescnativm of this city oo enter upon the
U O shavementiooted property fm inspection puryoses.
(We)agree m save,indemnify and kap harmlm the city of cugniom against
Q U liabilities.judgments.cmc coal C.M.which may in any way a«rue againsl said City
"Con
or tar grnntin f thio permit,
APPt CANE I+ SI'ANI. ANU WILLCDMPIY WITH ALLN(lN-1'OINI'
lZi SOUR"
REG N I ....w/�%
r..1 Sigmturt TApphc C.ul.tor I On •S /
HAZARDOUS MATERIALS DISCLOSURE -
WintheawlicantorfutureWildingacugm$true or handle harandous material Re-roofs
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Type of Roof
Code.Section 25532(a)I / YP
❑Yes
Will the applicant or future Wilding occupant use equipment Car devices which All roofs shall be inspected prior to any roofing material being
emit hssard.us it contumivnu as deMd by the Be,Me.Air Quality Managcnrnt installed. If a roof is installed without first obtaining an inspection
District? IAC✓^/ I a ree to remove all new materials for inspection. Applicant
❑Yes
Iha read the hamrdous oro 'alure9it n.oder Chagerfi95 of the Call.. understands and will comply with all non point source regulations.
fames�H�16tyode,ration 25N)5,255)3 and 25534.I understand than if the
M1uildiY cam Tdox..is my mponsibility on ifytha of she h ca m_smote or a Certo t tXcu
Signature of Applicant Date
Dwaef OrB en a
All roof coverings to be Class"B"or better
OFFICE