00030171 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: O mom„ �g^ I '
BUILDING ADDRESS:. I
- /� / �� • v1�C I��/ SANI'1'ARYNO. APPLICATION SUBMITTAL DATI
NP.
NIC CONTROLN
HG!!�53---71RU /05 s, 95033 ❑
CHITEC&NGINEER BALDING PERMIFINFO •3? J
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7> LICENSED CONTRACTOR'S DECLARATION
oc Ihereby affirmthen1amIiccnscdunder provisions ofChapter 9(commcaing Job Description
0:4 w wish Sation'/000)ofDiAi ion3ofrhe BusimssamR fmions Coe My imitator
o'< mmurnz� / `�^�/•9G.�� S AGrr�/`1�`/T/f�/T� j-7 L'
inaruc tier.g
3 z Dare Con
w 0¢ ARCHITECTS DECLARATION
aJ� un y plans shall be used as public records — a
w S°O u feasiorul
n nS o OWNER-BUILDER DECLARATION
F x N 1 lumbr aarm Jut I sun exempt from Ne Co..,&.License Law for the -
YO following.sen.(Sectimm]031.5.Business W Pmkncounty
Code:My city a coun
d3 whol to requires a permit m construct,alter,improve,demolish.a repair my suucmre /�M Sq. Ft. Floor Area Valuation
Mm
its
isruanre,dao requires the applicam fossuch Fusion to file a signed
ig dautament /l�JI.V �y
that he is licensed pmsuao tothe provisions of the Communities License Law(Chapter 9 C04+
(commeneing with Section TWO)of Division 3 of the Business and Profession,Code)in �pNN bar � ecupancy Type
Julio is 31.3 b therefrom and the aura far the alleged p thcant to Any violation of I i `,4.�/LJQI
Section r'th n byanyredapplicant. for(•permit subjao the applicant m a civil penalty of /(Q N! U 'Nr--05 T
wiof more than fee hundred dollen y employees
L a the wor erthe p ethrom a my emplended i ins wvgda a the(Sm.cempeuation, Required Inspections
will dothework.and these is Itor intended in Lao,
domrwaply10as woBuses
ness
and Hofwhou Code:The ove.thaContractor's License w law does not apply toll owns of
his own who buildt or improves thsuch i end who does such wool,himself or trough
his awn employers,pmvidm then such sem,I.sold anchor tic mu inrcnd a oBerm for
tale.IL howe.<r,the building m ins a movant is solddda mm yin r i.,.afar she /
gman f older will have the lumen of proving that he did mol Wild or improve far Wn
pox of We.),
L.as construct do,r of the Smperty.ens snows m!ely conpecting with li Theed urnmern -
e,Lathe project(Ser. r an owner
of and rty who Wilds
ds or i The Convsswr. red
apse law das not apply ie ere owns of pmpeny who builds err improves Nercmn.and (/
who contracts fa such pejau with acontrxtw(.)licensed pursuut m u
the Canrrtors 0
Licensea.Law. O
❑1 am exempt under Sm. .B&P C for this reason
Owner runt-
WORKER
ae
WORKER'S COMPENSATION DEQ,ARATLON
1 hereby affirm under penalty of perjury one of the following declvetiou:
have and will mutation Canificare of Cmsxnt to self-inwh
re for WoersCemper-
Wimn,as provided for by Section 3700 of the Labor Cmc,for the pe r..of the
.4work for which this permit is issued. ,
❑1 love and will maintain worker's Compensation Insurance,as required by Section
3700 of the labor Coda,for the polennsnce of the woh for which this permit is issued.
My Work e�eSCnmpc�ns�nio�°�' carrier and Policy nu be '
Carie �S/C "r r-N�7 Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ration nem not uncompleted if Ne Permit is forone hundred dollars(5100)
or las.)
m I ccnify taut in the performance of the work for which this pennon is issued.I shall
Out employ any person in any manner so as to became mhjmt to the Worsen'Compen-
WhoLawsoff mia.Data
NOTICE A LICA if.alter making flue Ccnificene of Exemption,you should
fare.mbjat to Ne Wortrr's Compensation provisions of the Labor Cora Y.mourn '
forthwith comply with such proviaitim on this permit shall bo droned revoked.
CONSTRUCTION LENDING AGENCY
Q I hmeby affirm then there th
is ammum,mmlemim,tigincy for e perfoonvnee of
,Z h the work for which this pcmtin is issued(Ser.3097,Civ.C.)
Leaders Name
I:ndcr.Addre.
f� ^� I ttnify JJN'om
that I have read this application and msec that ma above iution Is
at correct.I agme to comply with all city and county ordinances and sum laws relating to
�D Z building conetmatlon.d hereby auixrim representative,of this city no enter upon the
U 0 above-memiored..openy for inspection purpoxl.
(We)agree m ave,indemnify and kap harmless the City of Cupertino against
f, bebila,es,jmgmems.cosoand expenses which may in any wryucmugmul said City
;. W in consequence M the rel of this permit.
k- Ili APPLICANT ON 1ST DSAND 11.1COMPI.YWIr"ALLNON-POINT
V z SOURCERF T S. -
Sign til AppliceAZA De
HAZARDOUS
IIRDataDO
US MATERIALS DISCLOSURE
Will the applicant or(.to.Wilding naupam more m handle Iuvrdm is material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Sm,!.255320t)? """ ��, Type of Roof
❑Ya a
Will the applicant or future Wilding occupant use equipmcm or devices which All roofs shall be inspected prior to any roofing material being
emit haamaue sur communicator as defid by the Bay Ara Ah Quality Management installed. If a roof is installed without first obtaining an inspection
0, °`"°""❑Yes No I agree to remove all new materials for inspection. Applicant
d
I h.ve read th0h— .rtqui menu mnduChager693 of Ue Gia- un erstands and will comply with all non point source regulations.
fomia IT alto&Sees 25505 333 and 25530.I understand thin if Ne
buildingdoes exnair in is my rtsponsibiliry mnmify theoccofNe wm m iuuame of s Milan
Signature of Applicant Date
Owner eutbo m,gent
All roof coverings to be Class"B"or better
OFFICE