00030113CITY OF CUPERTINO I
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:h
IT NO,
OO
O 0 ll
IUILDING ADDRESS:
a9 S ol�fp ✓�.
Lesp - -
Lr+N
i C.sr5IIe6 Dari
SANITARYNO.
APPLICATION SUBMITTAL DATE
3 z
NIC
CON171t0L0
CJaw
sew 3DsP C�•5f(2�
S3
4RCHaTC,OF,NGINEER
- BULDING PERMIT INFO
ere
q 62 9 a-/ 0 a
LICENSED CONTRACTOR'S DECLARATION
I herby .Birth Net 1 un licensed coder provisions of Ch", 9 (romnteeing
-
Job Description
with Section 7")ofDivision 3ofNe Business and Pmfcado sCode, and my licenseis
in full force and a n.
Lianee-qass _ —3 q—Li, a
1 understand my plans shell he used as public rmmda
Licensed Pmfessionsl
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Lew for the
following maser. (Section 7031.5. Business and Professions Code: MY city or county
which m Wne, a permit to construct, stn. improve, demolish, o repo, any aoumm
prim m iia issueee. Sao requbes the applicant foe such permit to file • sgmd statement
met he ie licensed pennant to Ne provisions of use Contractor's Liters, law (Chapter 9
(Mmmcro as wird S.M. 7000)of Division 3ofNe Bmi. and Profesios Cads).
On, he ie emmp therefrom aod de basis for the elbged exemption. My violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mmc than Eve huMrd dollars (5500),
I,asomer o(Ue propenY•mmY employees with waFauthcu sole mmpewtion.
and do feammf W the That
C marot intended eco. Man
4. m Mote, 0
and arty whom Code: The Co, there's License law dsu trot apply to lf owner of
property who Wheat or improve, m thueon, sed who don such work himself or through
In W ....... loyes, provided mm such improvemenu thin ret inteoded er offend for
We. If. oil-- with, building or improvement u aped within one year r improve donP r.
owneof wilder will have the buden of proving that M did not Wild u improve for per.
pose of sola).
Diu owner of the progeny, un culosively contracting wit &erred un ,tem'. U.
commuo,now
dons
(Sa. 7014,wner of nMn,.1a, but Code:i The Contranon. and whom Law don mat apply je ts owner of property wM builds or improvee thueon, and
whoceafor each pmlau with a contnmoHq licensed apuum pursuant the Contractors
License
Law,
D 1 er exempt uridm Sm. . B A P C for Nim ramn
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby MBrm under penalty of penjury oe of the following declarations:
D I have sod W ill MinWft eCeniOnte ofCommuo NIFinsum for WorkeTY Compere
setion, as pmvided for by Section 37W of the Labor Cade, for the performance of the
work for which this pemo is issued.
El I have and will maims. Worker's Compensation Imurance, as regsrtd by Section
3700 fthe Inbar Cab, for me pedomseme of the work for which this permit is issued.
M Worker' er and Policyn
Cartier: ^Mfo1 Policy No.�.��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need no bec nyuctd ifrhe permit in fortehandrddniton(SITU)
or kas.)
I certify that in the perfim maeeof0e week for which this permit is luued, I shall
no employ any pa.in 'OD
me n�a u m become jai to the Workers' Compen.
.tion Laws of Id.mia. Dag n s= 'a—d at sYp U
Appiwant
NOTICE TO A�I1r: HOW. making this Certificate of Esempion. you Mould
hemue: subject to me Workers Compensation Provisions of the Labor Code, you must
foMwilh comply with such previsions "is permit shall be demand evoked.
CONSTRUCTION LENDING AGENCY
0 0 Ihereby .11 mMas Mem iso constriction lending agency for the p,,f.c of
r
On wok for which this Permit is issued (Sec. 3097, Civ. C.)
Lender's Name
�1 7 Lemices Address
W F^ 1 certify met 1 have mad this application and mute mat the above information is
Gr correct. I agree to comply with all city and county ordinances end sum laws teleung to
s'7 z building construction, and forces ;mhorise epruenwives of mus city to ens, upon On
U 0 above-mentioned property for inspection purpoas.
W F (We) .Fe a nava indemnify and kmp hamdeas the City of cuperlmo against
�) Bebilities,judgmems,con. and epensna which tay in any way ecru, against said City
^mss ry in consequecc of me granting of this permit.
�+(sD APPLICANT UNDERSTANDS AND WILL COMPLY WITII All NON -POINT
SO REGULATIONS,
leg 3
SlFunuecf Ap aWCont t Date
RAzAp6us MATERIALS DISCLOSURE
Will the tt'licans or house Wilding nm Watt atmem handle ha einem. materiel
u defined by the Cupertino Munico I , Chap. 9.1; mrd the Health and Safety
Code. Section 25532(,)?
❑ Yrs
Will the applicant or future building acupem an equipment or devices which
emit hmardo o air eonummanu ode ed by the Bay Arc Ab Qual Management
District?
Dyes
I have rad me huardo s matedss nuuiemens under Chapter 6.95 of the Cal
forma Health & Safety Come.Smums 25505, 25533 and 25534. 1 understood that if the
building does no curmmly have a bmm, mol it is my oaponsibiliry to notify the occupant
-3I
A>Z441ge0
j.. Ills r n
iL! MAR 2 2000 U
I 1
j'
Re -roofs
Type of Roof
O Ca
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
I agree to remove all newnaterials for inspection. Applicant
understands and will comply with all non point source regulations.
Sig ture of A plic' Date
OFFICE
All roof coverings to be Class `B" or better