00040023 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 'O0
04C7 023
BI111.DINlG{ US 9'A
ADDR1
I1 1 `-7 Pa-1,5 V�r�S ( r g SANITARYNO. APPLICATION SUBM TT/A�L DAT
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NIC CONTRGLM
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.RCUITECnENGINIiER 1VL r� C- /' [� � BOLDING PERMIT INTO
µcoo p< J� 75 -C3G
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o vpwi i Loo dda I a CONlTUC10R'S DECLARATION Job Description
O z—p I hereby vRrm Net 1 am Iittn,e0 under provisions of Chapttt 9(conmevciog p
F=k`q Wirth Satrre 70g1)ofDivicion3oftW Bmiwasand Pofe,xioaCade.end my littnu is ////j��3
y 5 in toll(Oreo Nd of
�ie uPeae a C .D
Dae Cmoacmr
I_u.O g ARCR l to,used
DECLARATIO
1 understand my plans shell W used vs public rcmN,
u zy p O Licenced Pmfeasimul
t3 0 so OWNER-BUILDER DECLARATION
1 hereby afl ran that 1 am e.,nn,from the Como sexies License law for the
_S M following mum.(Sabo,]831.5.Business eM Rafrvi.Code:Any city or county
3 m which reggheS a pooh in construct.alma,improve.dcn'aliah,se repair any atmctorc requSq. Ft. Floor Area Valuation
prime an
its issuce,also requite,Ne applicant for such permit to fileaaigndnmen
vtet
that he in licensed pursuant o the provisions of the Contractor's License Law(Chapter 9
(cora vingwlthSmGan70oo)ofDivisim3ofdeBusiwaa feuiotuCde)m APN NbOccupancy Type
thudv
he is exempt thefmm ed the basis for rix alleged exemption.Any violation Number iolation of P Y YP
Sedon 7031.5 by any.,U.t fora period subjects the spirit.to•civil pemlry,of O
riot moreNen five loodred dollars(5588). 5N, 129 S
❑I.a.ownmurthemaperty.mmremploya,withw.gesathebroleeanrpeadm, Required Inspections
will do Ne work,and the structure is nm intended oroffered for win(Sec,7044,Buuness
and Prefessimss Code:The contractor',Lianm taw does trot apply to en scoter of
property wW bunds or impmvcs thereon.and who don such wort himself or through
in,own employees,provided the such improvements ere nm intended or oHesed for
sine.IL howaer,the building or improvement is sold within one yearafone'letim,the
ner-Nilder,will have the burden of proving that he did not build or improve for For,
pose of sale.).
1.as owner or the Property,un exclusively contracting with licensed connacron to
..I the project(Sa.7w,Business and Professions Code:)The Cantractmi Li-
ccme law does ton apply to en owner of property who Wilda m immm e.there4a,end
who contracts for such projects with a conosemr s)licensed pooment ro drc Contractors
Lianm law.
❑1 am exempt under Sm. .B d:P C for this recon
Owner Dat J /
p" Wunder s COMPENSATION DECLARATION
1 thereby affirmm under penalty of perjury one of the following declarations:
I have end will meimun a Cmifcam of Conaem to self-invert rorworker'a Compem -
atim,a provided for by Section 3708 or the Labor Cade.for the perfmi u se of the 10
mmv.��
ills peanut i,issrd.will maintain WmtrnY Compenadan Ivsun,rce,a rcquvd by Sationor Code,Por the performenceofdre work for whichNispermitisiaaudrxeti m c c m and PolicyK s e rPolicy No:(I CERTIFICATE OF EXEMPTION FROM WOREERS' V
COMPENSATION INSURANCE
(Thi,rad.nmi nes be complued irt3u permit is lorooehudrddollua(5100)
or Ra.)
I certify that in the performance ofthe work for whim this the wok iad,uI cheml
sat employ any Canon in any manner co a to becamau
e nlar nes the Wrtrn'Comtism.
lion Iowa or California.Dat
NOTIw
NOTICE TO APPLICANT:If,after meting this Certificatesoof Exemption,you should
h forthwith
h comp to the Worker's Compensation pmvit steal of the IaWr Crisis,you met
fanhwith comply with each provisions m Nix permit shell W domed revoked
CONSTRUCTION LENDING AGENCY
Q 0 Ihereby afro the them is a cmnmcuan lcdineagencY for the pnsfiri—of
z he work for which this pemdt is issued(Sa.7097,Civ.Q
Lenders Name
a j Ledcrs Addmaa
R7I eorify that I have mad reds application end stale than the above information is
d A correct.I agree m comply with ell city and county mdinanees and some law,reldng to
Z Wilding mnstrucdon•end thereby audismirnrtpreaenwives of this city to enter upon the
V 0ebovamemioned property for inspection Pumams.
Ia Fy (We)agree to nave,indemnify and keep hamtless the City of Cupertino against
(,) liabilities,ju)gments,contend apexes which may in any wey accmc against said City
} L4 in consequence of the granting of this .it
[-� O. AI'I'LiCANTUNDURSI'ANDSA DW C0slPI.NWI'Iu AI.LNONa'OIN'r
V z SOURCE REGULATIONS. / d0 y
Sign pplicendContrecro Date
I3A2orfor= MATERIALSDISCLOSURE
Willthe eCupentor fMuni Wilding acupento9.12,and tehationskers ealthaiSafety Re-roofs
a defined by the Cupertino Municipal Code.Cluptu 9.12,ural the Bcalth anal Safety Type of Roof
aria,Seaton zss3a.n YP
❑Vcs
Will the applicant orfuture Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being.
mi,haadou soconteminantaadefindbytheB.,AmaAbQualityManagement installed. If a roof is Installed without first obtaining an inspection
Dia^" I a ree to remove all new materials for inspection. Applicant
❑Yes � g
IMIMve read the haardaaa maeriale onaimmetm under chapter 695 of the Cali- understands and will comply with all non point source regulations.
fmda BWth 8 Salcty cede.savors 2525533 and 25534.I northeastern]dustif the
buildingdoes na cmrcMl
tt reparuibiliry ml
M ify the cccu sent
of �u�rhy�. sauerc yaCmifcata�(%upeay.
Signature of Applicant Date
owner�ja m,T zeddam, Oat
All roof coverings to be Class"B"or better
OFFICE