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00040097 CITY OF CUPERTINO - ' PERMMNO. BUILDING DIVISION PERMIT CONTRACTORINFORMATION: BUILDING ADDRESS: `[ .y �L�y\ Roy 1 ./•,S `/1^�v'a�� SANITARY NO. APPLICATION SUBMITTAL DATE OtYNLLA �+S Ag ii .r5 •t''-sV—�i\ I— V V /�•1k NIC CONfROLp one:T [, '0 E /v//V//�l////J ,!/V/1C\/) ❑ ARCHITCr/`ETNGININEER BULUING PERMIT INFO �00 mwG VUU LICENSED CONTRACTOR'S DECLARATION 0 z=in I numb flims that 1 am licensed under f Chapter 9(com armin Job Description �S e r Pmwmm�an w 8 P ,f C-JIC/.5_Y-L_I r'=tar, with Saani aDiviaion3oftM Business Profwiom Cole,WmYlimmeis muforce antes in bull dancer. 2 B«t. L kAn. GUS /152L'9-IV1Ll. - d i D Li"mc xCl.Class Con 3 o. Dam ConDECL f H LL p., As"Ibe mo DECLARATION 1 understand my Plans ilio))be used as Public records t « .2c S i d 90 Licensed Professional cu,H OWNER-BUB.DER DECLARATION I-Zx a 1 hereby affirm that 1 am exempt from the Contractors License law for the RF G following...(Section 7031.5,Business and Rdfasi...Cods:Any city or county a3� wldmregnires.perd'roc°•s'^rot•.l'e'•imPmve•a<nwi'"•°amP°i'•"Y'mmtm< Sq. Ft. Floor Area mV�lluation prim to its issued",also requires the applicant for such pemm e,flea signed am<reem that he is licensed pursuant m Ne pm,,um s of the Conmmume License Law(Chapter 9 •-- (commcmingwiNSecdon7000)of Divisim3ofthe Busimumd Profmiou Cwe)m APN Number Occupancy Type Nat ha is eaemq Nerc(mm W Ne breis for th<alleged cxemptian.AVY violatim oI Section 7031.5 by any applicant for u permit subjata the applicant to a civil penalty of 3gs-��., 3—O 2- o mom Nen rive hundred dollars(5500). Ido the waofrddW emotion otor is otinlorea wiNwega uthe'vmlc mmpem•rim, 'Required Inspections will do Newon,ands: ovucwn<idnmimertdw«oRcrtdfm utapply In no Buumu sew er y wh oro Code:The Contractors.and w Isco d"c n«apply m lf owner of to, We who oyior impmva Hereon,sed who doents such won himself"r nal for hid awn oweveemployees,provided r i such improvements meta�rt mt imcwed r ofl<rw for sales If.however,Nebuildingorimprovement idsold within t yearofmprovetim,rhe -Wilder will love the buds of genuine that ate did not Wild m improve for Pur pose of sowne u ower of Ne property.am cait canoacdng with licensor mntnnan m reme,construct the does (Ser.o an Business and Py who Code:)The Cmumtora U. / "nu Isco rs f o apply to ts income re progeny wce sedan or itmto the Ncmnn,send wW rse Law.f«such pmjecu with aconvaa«(G lived punmnt b dm Conmactvrs / License Law. - DI—exempt ev�suc. BkP owns—�1��-Dam L ©O fl� WORKER'S COMPENSATION DECLARATION 1 ncroy affirm under puvlly a PrrlurY oro of IW followingJOIdalatatiov: Q I have aw will maintain acmifcare cf Cummt to elf-imu ,for Winner.Compen- sation,as provided for by Section 3700 of the Lobos Code,for the pcnmmame club, work for which this permit is issued. D 1 have anal will maintain Winters Compensation Immature.m int,imd by Section 3700 of dm LaWs Code.for the perform.,of the work for which Nia permit is Word. My Workers Compevatien Insurance eerier and Policy number art: Catrin: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This soction wed rot W completed if the pemut is fm one hundred dollars(51 W) or lw.) I,any teat in he any..a, of the won for whim this the w is issued,I shall rot employ any person in any manneno as m becuty subject m the Winners'Compen- sarion Laws of Cad i l"!! on Applicant NOTICE TO APPLICANT: a amakingthis oviii gofm Exemption,gCyenshould become subject Nt Wonder Compen1'his p.iisihal of Na Labor Cade,eau met forthwith comply with such proviaiov or'his .it shall be deemed revoked CONSTRUCTION LENDING AGENCY Q p Ihereby.Biro Nat Ncrtis a cmtsumddn lending agency for the perf.-of Z Ne work for which this permit is lute<d(Sec.3097.Ci,C.) Ftinders Name y > Lewers Address 1 extra,and 1 have a appli'mi.and state that the above info Wei is Ft A rcw tnitorten.I agree to comply with all city andcounty ordinances and sum laws belaying to .7 Z building cosuam uon.and hereby amhorim rtpscuntativa of this city to enter upon the C.1 eWve-Immo n d pmpmy for inspection purposes. (we)agree to save,indemnify and keep hermless Ne City of Cupertino against Q V lieliditiegjudgments,cuta..d espros,which may in any way accrueagam,said City } kl in rmorquem<of Ne granting of Nis permit. tiS APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT DO SOURCE REGULATIONS. V Signature of Apphcenueonuector Date HAZARDOUS MATERIALS DISCLOSURE —��((j••MMM Will she applicant mfuuue Wilding occupant arm or handle bacoolms matmd Re-roofs in deftud by be Cupertino Municipal Cade,Chapter 9.12,and dw Haldt eco Safety Codr,Section Type of Roof 25532(.)7 yp ❑Yes KN. Will the applicant or future Wilding occupant use equipram or devices which All roofs shall be inspected prior to any roofing, material being runithudoua air conumimnts as defined by the Bay Arca Air QtWity Management installed. If a roof is Installed without first obtaining an inspection Di` k,7 KN-r I agree to remove all new materials for inspection. Applicant l have teaddehawdmvtumnalcmyuirtm" under Understands and will comply with all non point source regulations. f«nia Health R Sdery Code.Se Wmu 25505,25533 and 2553x.1 understand Wt if the Wilding d«a n«curtently have a mend,that it is my uspumibility to nmify the occupant of the rtyui"nomm,which moil W met palm 10 issuance of a Cenificam nal Occupancy. Signature of Applicant Date Owmrmautrixw of eI 1� /Dte L C)D All roof coverings to be Class"B"or better OFFICE