00040173 (2) CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION RMIT C [ NTRA IO L OO R ASTiIOg
BUILDINGADDRESS: 012V an - T •- OOO �O) 73
rf♦EI[) /�� �/A,�, SANITARY NO. APPLICATION SUBMfITAL DATE
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NIC CONTROL
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LICENSED CONTRACTOR'S DECLARATION
O
q T hereby s0immth ars
ovisions of Chapter 9aomnm..is Job Description
W
with Seoion]OW)of Di 3ofthe BusimecandProle"
licenmis
¢ ,ui ce4llatco
,,rou a
e
0 y 'Dae CHITECT'S DE .
ISE vera 2 1 und.slard my plans"I W used a publie recmda
4 p o LicrosW Rofeuionel- t .. - - .
OWNER-BUILDER m the Com ION
t?< 1 hereby aRrm that 1 ata cumpr from the f mt...Cos Licence Lew for the
?❑ following mason.(nation IDS L5,Bualter, and Rofewnns Cade:AnY cora.munry
u.3$ -which rtquirts n pwerrnsuu.re cam,flus,, aiter,improve,demolish,fi repair any aaYCmrc � 3S7. I7 Floor, ar5iVr ^
pdmmibisssed e.retention
mquirte flus, of for Each CramosmilbFlleuignWmmmant t�'-I/ .`//,,ly 0 VY9 UY
(cochat n encis ingwi mtolh Provisions h cRusi are Ldc oelaw sionsC(chapter —�
( ,the I,inewithnection1000)af Dlvi,for dNe Bueinext antltim.A.ion.Ctimof
U,he is 31.5 b Nercfrom and ted bssis for me cts the exemption.Any viogtian of APN Number Occupancy Type
Section 103L5 by any applicant for a pemtio mbj.0 the applicant to a civil pemlry of
not m
more men five hundred dollars(5]1)01. •
1.as owner of lh,property,or my imployees wiN wages tui Neinole amps...tion. -Required Inspections
will do the work.and the structure is not inteldedminfered f osse(Sec.1044.Busimka
and Profession Code:The Cesar ior's Lt...U.does IKK apply to an.d .
plopeny who builds or improves thereon.and who does such work himself or through '
his own employees,pmvidW that such improvements no,not intended or offered for _ -
We.If.however.the,Wilding orimgovemml is sold within one year ofmmplWon,the
ownn-Wilder,will hese de,burden of proving that he did not Wild m improve forDur-
pose of ole.):
r ❑1,a...of the property,am exclusively contracting wlth licensed Cmums.oa to
contract ted protect(Sec.11144,Business and Professions Code)The Contractors Li-
came I.Ew does.,apply to an own.of property vile,Wilds or improves thereon,and -
whocotsactsfor such projecla with a cremations)licensed pursuant in the Contrwtore, n -
ucrosel.v.
❑1 em coapt under Sec. .B Q P C for this meson
Owner I •Date
WORKER'S COMPENSATION DECLARATION
1 Wrtby afro under penalty of perjury our,of rise following dmlamliom:
Ihaveondwillmaimm a Certificate dC.mc too self-im e,for Workers Compeer. _ -
Wion,as provided fm by Sxum 3100 of the Latin,Code,foi the pcofolmmce of the
work for which this permit is issued,
D 1 have and will maintain Walkers Compensation Insunmwe,at required by Section
3100oflhbor LaCode,for Ne pc ren of me work forwhic emllis iaeued. '
' Ca Work tion lm c umYyrp•-pyaff M,
Cartier. 4a�
CE IPICATE OF E%EMPoO BOM WORKERS'
COMPENSATION INSURANCE
,(This acti a ncell�maleEe���/Q'}'�j��gJl�/�JICy�9 J�/tj�gg�/�u//��d dollen l5l W)
.1<ss.l - 4'T/�/emfalcedrJlCwafk df Whig "fclmi
P
I OnplfY tin the f C Ihia liussued,lahail - -
nm employ any pawn iany manner w as to hcome xubjmt to the Workers'Compeer-
sationanws o(Cali(omis.Dae '
Applicant -
NOTICE TO APPLICANT:esarom meting this CertiFlcete i f Baemptim.You should '
h¢nitc subject m it Wanda Compmuuon Provisions steal of me Labor Cade,you nun -
fmthwiN comply with such provisions or this p<nnil shell Is,xemed rooked. -
CONSTRUCTION LENDING AGENCY •� I
I hereby affrst Often mem is a construction lending agency forth performance of
the work for which this permit is issued Sec.3091.Civ,C.)
Lenders Name
�i ;u- ILndets Address .
W Q1 c.tify that 1 be.rcW this application and sum ed m that tabove information is
� Z correct.I agree to comply with all city and munry ordinances and also,law,missing m, •, - ,.
U O bulldingcrosouction,and ha etyeutromic,re,immulives of this city on enter upon He, ,
above-mentioned property for inspeeuon purposes -
W [� (We)agree to save,indemnify and keep harmless the City of Cupertino against -
'0 U liabiliues,Oulgmmte.emu and expenses which may in any way wcsue against said City
} W In conaequeoce of the grating of this person. - -
rFw U') APPLIC NDERSTANDS AND WILL COMPLY WITH ALI.NON IN'r
U. SOUKC. 1 ULA`ION �
Si�pmmt/Cmtrwtm at D)Ely
IIATARDOUS MATERIALS DISCLOSURE
Will the applicam or future Wilding occupant arms or handle haaaEous material Re-roofs
as defined by the Cupertino Municipal Cede;Chapter 9.12,and On,Health turd Safety
Code,Section 25532(.)? „ . 'Type of Roof - 1
s Dyes o
Will The applicant mfumm Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
call limundous air commnimnls as defined by the Bey Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
❑Y. gg I a ree to remove all new materials for inspection. Applicant
�o
I hay the tonsandone,matenairtgoi
a mmmisnnder Chap¢i 6IW.95 d Cali- U. standg and will comply with all non point source regulations.
face.H Sar.Y,Code.S.doro 25505.Vao and 23534.1 and Na HOW '.
Wildin s No. Mysore tene Iirrn,es: ra.Nliryp fy pant
'ofthe, qui n hmua met sofa C''lh77n.JJOg(( f
ownernra mm,e .geTV• „� ,DL Signature of Applicant Date '•
All roof coverings to be Class"B"or better
OFFICE