00020048 CITY OF CUPERTINO - w
BUILDING DIVISION PERMIT CONTRACT -'' C)o p;20Q L/7
BUILDINO ADDRESS:
�� ey W/?tEGNLY,/NC• SANITANYNO. APPLICATION SUBMDTALDATE
OWNER'SF( ME: 970 E. MAIN OT #'200 NIC CONTROL#
/IP am
mil N::: 9910- 702 6/2455 VA116Y, CA 959,15- ❑
ARCHITECT/ GINEER /—Add'S334572 ISULUINOPERMIT INF<I'-`;,te`' 'a
�00
U
t' n LICENSED CONTRACTOR'S DECLARATION
z o n 1 Mepy alfitm Nal I w IiccaM under proviAoa of Chapter 9(wmmrcaing Job Description
O�huNj wiNSection i000)of DivisionJrfNc BUslaaand Prrfesim.Code,Wmy 'anuis '
f -J
s YS, in fuR fares and t t. �t/at�� NentPr lPeplae2meat
C W< V^..•• lass tic.#
LL S i Dau Contnuwr
" OEC ATtON
1 understmd my pass shAI S plans be used as public rce.ds
LLa<f
n a Li<rnud Professional
oS=a OWNER-BUILDER DECLARATION
C Z a 1 hereby a(Srm that 11S exempts m the ContractoYs License Law for the
dF following season.Mmioto mar I.9.Business ad Professions Cade:Any city or county
0.1mtydrea.permswc«c,theAtr,iftfi-mdemaratt««p.ilanyn.rmre Sq. Ft. Floor Area Valuation
Nimmlsscensed ,ileorequitesJaeai,mmOftheI bpemut.filnseLaMnname. 7W-DO
Nat hoe camM pursuant to N)of Divisioor the Canamoss Licenulaw(Chap)9
(commencing he
ixewiN SatimIOWThetirdiofrof Neeged eta ondon.Any vCmOuOf APN Number Occupancy Type
Nam he is exempt Ncre(rom and the basis(.r the alleged exemption.Any violation a( P Y YP
Sacrion)0316 by any.##Gear form pemut subject the spplicanuo a civil pealry or 35<0 - Q-o ff
Q01 nprt Nan Bv<huadred dollars
I.an caner of Ne propeny,ormy employaa with wag<su their sole comaaation. Required Inspections
will IN the work.and the someone is not intended us offered for We(Sm.7044.Business
and inty whiotu Cade:The vas danoz i License law does twt apply To lf war gh
his own who builds a improves thsuch i tend who date such work himintended
or«Juvugn
his own oweveraa,provided Net such imp..sold
art not inaMW o oRDrtd for I
xamdaIf. will
Wilding oirisof omen ie sold did noneyldot,I mpla for the
wvcrWilder will nas<the Wmdcn of#ruins Net he did not Wild«impmwe for Pur.
pose of sole.).
L a owner,of n proper,%,B ,im siwly co lescWg with licensed c.noactn - O
co..La Jt es.. (Sec..an Business and Property
TW bui Cade:)M Canamons V v
ceou law does e«apply ter ts owner,of property wce milds or improves Centro,and
who contracts for such prolate with acrntecla(a)licensed punwm in the Contemnor.
Lieuue law.
❑1 am exempt under Sec. .B At P C for this wan
Owner Data
ECL
WORKER'S COMPENSATION DARATON
1 hereby affirm under penalty of perjury one of Ute following decla.,iorv:
1 have and will maintain a Certificate of Cornet,1.calf-inrom for workerCooper.
utia,a pmvidW for by Section 37W of The labor Code,f«the pctforuae of the
k nor which ria phmut is issued.
1 hove aM will..Irwin Worker's Compensation Insurance,a required by Section
W of the labor Code,f«the performance ofthe work for which NNS permit is issued.
work Com Ina terrier and Policy n
Cardcr:�TATaUNI "` Policy No: Y laV
CERTIFICATE OF EKEMPIION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed ifthc permit is forone hundred dollen(SI W)
«len.)
1certify Putin The any
oast be, for which Nis throat is Naaed,lshall
no employ any person in any m «r so a to berome mhjec,to 1M Warkrn'Compen-
a1l.n laws of California.Data
en
Applicant
NOTICE TO APPLICANT:IL after milting this Certificate of Exemption,you Could
nemme object t.th<Workers Comtena,ion prvisksrl of the labor Code.you mutt
No hwun comply with Such provisions or this permit shill W domed revoked.
CONSTRUCTION LENDING AGENCY
Q Q I hereby affirm Jut Nem is a concoction lending agency for the perfoounce of
Z the work for which this permit is issued(Ste.3099.Ci¢C.)
Leaders Name
nder s Addrax
k�r7 > fiI certify Net I have read dur application and our that me above information is
6• Qcae I agree to comply with all city county areiaan and soh laws relying in
.7 Z rtbuilding consuuution.and humbyauthmiu rcpreaeotadwa..fthis city,.coon,upon W
U 0 am'u-mentioned propeny for inspection purposes.
!z F•, (We)agree To ave,indemnify and keep harmlea Ne city of Cupertino against
V habiliti"judgment,<osuand es )ch may in any way ucr<against said City
�.r 4g7 in consequence of the 6.«Ingo rs pumu
F- h APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NONPOINT
All
SOURCE REGui 1 _
Sib rtof
Data
Appban C uacm,
H RDOUS MATERIALS DISCLOSURE
Will The applicant or future Wilding Occupant at=or handle handous material Re-roofs
a defsad by IN penin. unicipal Cadc.Chapter 9.12,tad se Health and way Type of Roof
Code.Section 25532(.)? a YP
Yes
W 11 the applicant«future Wilding Occupant tau equipmem or devices which All roofs shall be inspected prior to an roofing material being
.mil h.!'d.us dr tchimin<nu as defined by the Bay Arta AB Quality Manallemcm installed. If a roof is installed without Irst obtaining an inspection
iankt? I agree to remove all n w materials for inspection. Applicant
V<s g
I Hour mad the lianuwiAa ImOiament ander Chapter695 of the CAI- understands nd.wil omply with all nonpointsource regulations.
(.mite xralth&Sdny Code,Sav«u 25505,255JJ d]5534.1 understand Nat if doe 1 D a-ons -od
Wilding docsn«curren,ly haven ant,Not i, Y:Zroilah"w rwtify the occupant
orthcrequverneatswhwhirs,t n ta..ana.f.ccmtioile�o rr <
nature ofApplictv
Date
r or auNwnzM eget Uaon
All roof coverings to be Class"B"or better
OFFICE