00020168 CITY OFCUPERTINOYF=i" - PERMITN(;.
BUILDING DIVISION. PERMIT CONrTRAC°}TtOR INF,fORMAyTtION. /—
BUILDING ADDRESS:
0002-0.1
J-IQT^�Gf)jlM/ c__R jY0•/y/�5VT7Dszs SANITARYNO. : APPLICATION SUBMITTALDAn
O 1eH'S NAMF, A/ Z SCJ/ f../rGL GIQnLL /!�i - r
vm M�' r C'<lrloy ,•C� NIC - CON'i ROLg
ARCIII"I IiC1��N1,TR ���" ���-���� , El
2-5-
.00
�.� LICENSED CONTRACTOR'S DECLARATION 'I s i • -
O Z=E ''1 nertby niton that 1 cid licensed under Provisions of Chapter 9(c noon,• , ";Job Description
ant J with S«don 7000)of DivizionJorthe Busineasana Rofessiau Code,.d 1' nee is
«�W ViLig.
h oro midl�U,•. /LI G ._✓ L( � ••G�/ G
3 un.H °ale--974 Conlrvclw A ,• -
to ARCHITECT'S DECLARATION -
f 1 unde m d my piano shall he used as public muds..
cLicrnud Professional
oS— OWNER-BUILDER DECLARATION
C>< „I 1 hereby M.that 1 am eaempr from the Coasracme.License Law,for the
�s O following reason(Section 7031.5,Business and Professions Code:Any city«county
Ed3 whit],residues.permit to cquwm,al W:improve.demands.or repair any mnam« Sq. Ft. Floor Area �Valuation
-prim
to its keessuce.also"nice,this,W icmt f«such perWm t li a signed statement 'J DO•G�
Nm he is limmed puma],,to the provisions of the Coco«tate License law(Chaper 9 V
(commencing with Section 7W07 of Division 3 ofthc Business and Professions courier' - aTICY TYPC AP Number QCCU
that he is comp,therefrom and the basis for the alleged exemption.Any violation of D P .
Secdon 70313 by any applicant fm a Femsir subjects the st,,ficand to a civil penally of
-p I mom thm Give hurdrd dollen(5500).
I.asewMrottnemopeny.«mycmploy«.wimw+gua,mar>oiccomp<nvdan, 4 Req red Inspections
will do be work,and thesouaure is trot imended oroRaed(estate(Sao7044,Bmisusa � t
and Profesaiom Code:The Contri License law does not apply m an owner d '
property who builds or improves dtersan,and who does such work himself or through _
his own employees,provided thea such impovemew arc rum intended or offered for
sue.if,however,rhe building or imparenrnt is sold within one year docmpletion,the
owmnW ilder will have rhe burden of proving that he did nm Wild or improve for par- « - ,
Dose of aale.E
I,as ounce,of the Property,an exclusively comment,with licrosed conmac,«a to
.rowel the proj«t(S«.70414,Beason.ad Profeuiom Cact:)The C.Im s Li- ,
cense law does WE apply to an own«of property who Wild in impra.es dwaenn,cid
wh.,W.clsfarsuEd 1.the Cemractor, a '
Licer.Law. - r
I an exempt under Sec. .B R P C far this
Owner Data
WORKER'S COMPENSATION DECLARATION -
io1 hereby affirm under penally of perjury one of the following doolaratics.
I Iu.and will mainum a Cenificak of Consenu.self-inume for Workeb Compere
cation,eaprovided for by Section 3700 of the Labm Code.leader prdwmnu<of the
vhr or wnicnthispermitisissud.
m W will mainuin Worries Compensation Insurance,as required by Section
3700o`the labor Cede,for Use prdooname of be work for which this permit is issued.
My w fl,mj- oral Inau "m and Palley najbecypL3 y�
Curiae Polity No.: 5 7 4 ,
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
• - COMPENSATIONINSURANCE • I - -
(This section need not becompletdifthe permit is forea ebudd dollars(SIM) ,
Of less.)
lemony thm in the any m a«e of the beemordhichthi.dic W iicrsud,landl
'soli employ any Pana],I.my manrkr to as ro bcwme rubj«t to thr Workrnt'Cmnpcn-
ApionaawsofCdifomiwD�c
pplicant
NOTICE TO APPLICANT:If,after reeking this Certificate of Eiempdon,you should -
hecome sub(ect w rhe Workrta Compenvdan provisions of the IAWT Code,
you
aeu ,
forthwith comply with such provisions m this permit•lull W uecmrd evoked. -
CONSTRUCTION LENDING AGENCY '
O p (hereby of oto that them is a commcdon lending agency for the pedo sat sof •• " s
Z the work for which this pare it is unwed(Sec.3097,Co.C.)
.�., Ledets Name
LenduresAddress
[Ta 1 certify that i],ave read thin appliution.nd swe that the+W irdmmadon is s
P. z correct.I agree to comply with dl city and county ordinances cid a c laws mining to - - -
7 Z building conswcdon.rnJ ncroby amhodse rcDresentnives of this stytoriono. onthe -
U O abavo-mm,iamed propmyfm inspection put«ncs.
La. (We)agra m live idemndy ad kap hsrrnless the y of Cadman.cal Cil,
O V liabilitica,jdgmcnis,creta anu cxpcnxs which may many Yeccme agdmt uiO City
} W -in comequcsicr of gr IinB of Nis troll. -
F a' AVVLICANTUNI [ AND' II WILL COMP ITH ALI:NON-POINT � .t 4,
V Z SOURCE REC II I
Si,W,EEEEmfAp,lt,.M1ff],],actor / Date "
HAZARDOUS MATERIALS DISCLOSURE _
V
will dreapplirentoTfu,—building occup—mr,wboost hauNommalarial Re-roofs ,
as definedby the Cuprnmo M�I Cde.Chapter 9.12,atd the H W th lid Safety Type of Roof -
Code,S«don 25533(p7
❑Vas '. - ': .. i.
Will the applicant f Wldinemrapmt.a,a .gaipment0;&vie"which All roofs shall be'inspeeted prioi.to any.roofing material being.
emlihvarl."Eurcantamiruntsas fi.dbytheRkyAruAirQudityMan.gemcn, installed.-If a roof is installed without first obtaining an inspection
}° m'oYea r q I agree to remove all new materials for inspection. Applicant
is "r understands and will comply with all non point source regulations.
1 a Health
read the Coda,Se mucrids 5.Z13menn dda Chapter fi.93 of dre Cdi-
• Tania Health&Safety Code.Sections;25505,2131)W 25534.1 uidmtatd that if the n -
WiMi',Was miss currently how knun dei it is my responsibility to atify die aupord _ 4 9r D0
of the«yuimmenu inb psimmiiswncc of CmiOceu of Occup c
0 Signature of`App Date.
, I ,
ownermaodamo
All roof coverings to'be Class`•B',•or better
OFFICE