00040165 CITY OF CUPERTINO PERMINo.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
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eCIIITECfIENGINEER 7 �s /�J HULDING PERMIT INFO
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oro LICENSED CONTRACTORS DECLARATION Job Description
O _ I bershy affirm Net 1 am licensed under i mvisiom of Chapter 9(comtrRrcing p
<__J wiNScrion T000)of Div"an aI'Mo Busixnrund Rofosamse Codc.aMmylimmic is
°� < in full force end offal. �. s �-
u7 3 u y Date 11 CIa Convector
f u O gARCHI'1'EC i DECLARATION
f y} I understand my plash shill is used as public reada
as Licensed Rofeaaicod
w
OWNER-BUMDER DECIARATION
C z< 1 hereby To.Net 1 am,sump,from Ne Conuecmr's License Lew fin the
F O toles ine reason.(Section 7031.5.Business and Fro(icau Code:Any city or county
un°I 3 c, which requites permit a peit m construct.alter,improve.demoting,err Input any stromme Sq. Ft. Floor Area �7 'tion
prior m its iaoonce,dso requires the opplicatmt fa ouch pertit m file a sigad sute.,em `f
that he is licensed Forma.,to Ne provisions o(the Corpo ctoes License law(ChsIpter 9
(commencingwith Section 7WO)of Division sof Ne Business and Pmfeaions Cede)« ped Number Occupancy
Wt W is acme thaef sm and the basis for the dd a
ict emption.Any violmon or Pane Y Type
Section 70313 by any splicers for a permit ubjects the,applicent to a civil pealry of
pt maNan five hundred dollars($500).
mart Man
I,as owner of Ne propemy,or my employees wish wages 0 their 9010 comprnastian, Required Inspections
will do the wort,and Ne structure is not intended or offered for We(Sec.7061,Business
od Professions Cal:The Cmmacmri Liamse law does,trot apply m s an ownd
property who builds or impmvu thereon.end who does such work himself a through
his own employers,Mviden Net such improvements art not intended or offered for
wale If,hwmer,the building or improvement is sold within one yearofcompletion,the
owner.WilM will have the When of proving Net be did rout build or improve for Wr-
poreofWoroer.). J /
Q I,u of the property,am exclusively cooVcdng with licensed contneton to l
nsvea d project apply
.an Business and Al who Wild,
Code)The Convenors and
�/
Li-
sense,Low does not apply m m owner of prnpeny who bandsm improves thereon.arta
Lwho ist..Law.faauch pmjau with a convenorfH licensed pursuant m the Conuecure O
license few. O
Qlam escmplunder 5c. .B&PCfor this lawn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aRmm order pendry of perjury,one of the following declartioro:
1have endwilllfor by eCmilate of Corentr Cods.wre for Workers Compche
rim,es prvided for by Section 3700 of the Labor Cade,for the perfomunroe of the '
o
havewhich Nis Falcon is issued.
v e and will maintain Workers Compensation Insurance.h required by Section
ofdrc lab.,Code,mon
pe Ice creno of role work for which this permit is issued.
My Worke's C rim Insurax oma and Polity n aa:
Curler. � tr Of le c Policy No.:� P/i00101 k,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(Tris scrim need.brecompinrd ifthe pcnmit is forme hunched"Ins,Is100)
se Ica.)
I comfy Net in the perf monoe of the work for which this perm is issued.I shill
not employ any person in any manner eco as N become subject to the Worlora'Compen-
utiom laws of Celifomi>Date
Applicant
NOTICE TO APPLICANT:IL after nuking this Cenifuare of Exemption,you should
become subjcuo the Workers Compensation provisions of Ne L.ebor Cade,you must
forthwith comply with such provisions or this permit shall W domed rooked.
CONSTRUCTION LENDING AGENCY
O O I hereby affirm Nat Vert is a corm.d..lending agency for the pe1f.e of
Z to..it for which this permit is issued(Sm.1097,Civ.C.)
C4
Lenders Name
([ 7 Leder's Address
WC I cenify rout 1 hrea
It...read W.application and sum,rout the above infveoadon is
0. correct.I agree Io comply with ell city sodcounty ordiwaa and state laws tetrall Ion
D Z building comtmcdon,rd herebyedwdse repmaenudvo of this city m enter upon the,
movememimed property for inspection paposca
IL E., (We)egret I.wave.indemnify and leap harnea Ne City of Cupertino egdmt
O feel liddidesjdgramu,err ad..pores which may,in err waY rcme agdmr said City
in emsequmce of the granting of this permit.
AI'PLICAN'ION DERSTANDS AND WI ILL COMPLY W I'I 1 I ALL NON POINT
V Z SOURCE RRGU LA I'IONS
SigruNm of Applir mnVa pr Date .
HAZA HITS MATERIALS DISCLOSURE
Willthe app¢.,or fowl Wildingacupem stem or handle havMoua material Re-rOOfs
in defied by the Cupertino Municipal Code.Chapter 9.11 ad the RUIN and Safety Type of Roof
Code.Semen 25532(a)? YP
❑Yes No
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit Womous err comernbunts m defined by the Bay Amo Ah QWiry Mwgcment installed. If a roof is Installed without first obtaining an inspection
DaRir17 Yes I a ree to remove all new materials for inspection. Applicant
❑ No
Iba mal the �s
ebaaaamateddaregairmran
endenehapra695nfNeCall- understands and will comply with all non point source regulations.
ramie Haw a Safry Code,Savour 25505.15511 sued 1553,1.I udcrud Nat if the
building does rmotcurundY Nvek re.,LNmit isresponsibility to naifY Ne a'emN^I �� t 7 �O (/C/
of the nyuiremenV h muss con Fria N issuance of a Ceni(cay a Occup y.
9 Signature of Ap licant Date
Owner or euth ed.gen U e
All roof coverings to be Class`B'•or better
OFFICE