00030018 CITY OF CUPERTINO /'%�Nr
BUILDING DIVISION PERMIT 'CONTRACTOR-IINEORMAT-ION: 0003ERVtJ1
BUILDING ADDRESS: /'/df�p� �/Y.� /{/�'/ SANITARY NO. APPLIC TION BM ALDATE
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H N LICENSED CONTRACTOR'S DECLARATION
0 0=o I hereby eRrm Net I un licenced order provisions of Chapter 9(m rcin9 Job Description
zsawihS'-Imn'UK)Iol Divi, n3 f Business ma Cde dmyr //�// //� �i �j)r Ayj�
nfmlrortnanaeReoL / S ��f�` /IeG1/�/ �` LLLG/iiL[�«/J
O i O Licensae Cl
Coatrmmr
r u O ARCHITECTS DECLARATION
I undermaM my plans shall W used as public records
¢ca5
u a o Licensed RofeuiplW
OWNER fo DECLARATION
I—Z< 1 hereby.Rion that 1 am exempt exempt from Ne Contractor's is Any C law for the
m O following won.(Salton 1 o str Business,War, and improve.
drool Cuda:Any city sensation rounty
3 which mquirts...marl to conwe,Ater improv..demolish, fi mpale anyhetheSq. FL Floor Area - ��a uaJiop
pna to its isswnce,Am nmuims Navisio cant for such permit Lieu a,Law(samcmcm d
that he is licensed pursuant m N<proviaiona of the Connmmh Licrnse taw(Camper 9
Icnmmening with Secfon 7000)of Division 3 ofthe Business ad Peoreninn Cone). APN NuOt{{{��� r Occupancy Type
he W is Camara ahercfrom gid the Wsis foe the alleged exemption.Any sunburns of
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of !f U✓meg L
pof mom Nan five hundred dollars($500).
I,a.owne�orth.�roparty,ormrmmpTray«awed.....as Ncirmleoompeaeeaon, Required Inspections
will dodr wort.ands: heConttactor imeddor awdoesnulapply 1014.BuAnu I
ad lamachy winos Code:iM ,.thearh Linens.law does oat apply tom owner d (�y�/ J�/I_ gL
his o nY who builds pr improves Normo,and who nest such wok himsslf Of through
his own however,
da,provided that such improvements art not i1.of i Offered for
role.If.however.Nebuildingoran of rmem iesaid within oneyearofm rove for the
no ando,r win have tM WMen of proving that W ala not Wad a improve for peer- //�/
pose of sole.).
❑I,u twos of ct Sec.704 nn exclusively limitations with:)Theed conteaon i- ,^O
construct the project(Sec.104x,Business and Pmfesslon Code:)lar Conhmtort V- 0/
cense law does nut apply to an owner of propmy who builds or impm...Neon,and
who concocts for such projects with a concoaona)licensed purmait to the Cansrnetols
Harare law. '
I sm esempt oder Sec. .B Its P C for this was
Owner Do
WORKER'S COMPENSATION DECLARATION
affirmdty, -
1fa oby under pen ,perjury sur ofthe following declan:
ratio
1 Wve.dwia mAnufn.Cohnimate of Casssnt m smif-ineae forworherS Comfort-
I,
ompcm
to u provided fm by Section 3100 of Ne Labor Cade,for the perfomrrre of the
as fof whichihiRpom isitud,
I Mve and will maintain Worlaces Compensation Insur.ne,n rtquited by Section
37IUof the lobar Cak,for the performance of rhe work foe which Nis permit is issued.
Afy Wprker's Cy1l�eygum a and Polley num .i '
Carrier:�IµT G YU�✓ Policy N.': ���)
CERTIFICATE OF 11MMPIION FROM WORKERS' -
COMPENSATIONINSURANCE
(This section need not W eompletd if Or permit is foron hundred dollen($IWO
or lea.)
I certify Nat in the performarce of the work for which this permia is issued I shall '
not employ any person in my manami an as to become subjest an N.Wo M'Compan-
utim laws of California.Dar
APPlicanl
NOTICE TO APPLICANT:if,afar malting this Certificate Of Exemption,you should
become subject to she Wortr/s Compensation provisions of Ne Labor Chile.1.must
forthwith comply with such provisions in this permit"I W teemed mokd.
CONSTRUCTION LENDING AGENCY
QI heaby affirm that Nem is a constomion lending agency for the landurreanee of
= um work for which this permil is issued(Sec.3091.Civ.C.)
Lodela Name
Lori Address
> I i unify Nat I base one dna aWhasniont and gams that tam above iMomutim Is
0. zconnect.I ti mm to comply with ell city and county Ordinances and wase laws elating to
Z building construction.and hereby sahonm mpmssntatives of taus city to enter upon Ne
V above-mentiond properly for inspection purposes.
Lr. Fw (We)agree to use.indemnify and keep harmless the City of Continua agalnt
f•) needles.judgmenta,costs ad expenses which may in my way income Mount said City
�... W n ronscqucnu o W granting of Nis K
F ,APYLICANTI a ISTANLIS ANI LL COMPLY WITH Ai,I.NON-POINT
V z SOURCE ' 'IONS.
Signamm of App ioral sm
DoMATERIALS DISCLOSUREWill applicante applicant or fumrnrt Wilding rocupenlfmm or handle huWous menial Re-roofs
in defined by the Capcninn Mania I Code Chapter 9.12,and the Health and Safety Te of Root
Coal.,Section z 532(.)+ t� YP
❑Yes No
wee the:#pain.,pr future Wading mcapmt use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit heaudous airconuminmu.s defrd by the Bay Area AU Quality Management installed. If a roof is installed without first obtaining an inspection
District' I agree to remove all new materials for inspection. Applicant
Yes
IlA� �h- O amUmtlal, mrntand rCLaperA95nfdrGli- un erstands and wi omply with all non point source regulations.
fay.Hede.Savo 25533 ad255)x.I udrnten0 shot if dr ��Wilding dhave um,Nat is is my rtapnibihty mortify Ne occupant Coftamnqmet pdw to issuerce of a Ccnificate f(lase y.
Signature of licant Date
All roof coverings to be Class`B"or better
OFFICE