00030130 a -CITY OF rids a%RTINO PERMITNO.
Ar"-:y(NG DIVISION PERMIT CONTRACTOR INFORMATION: D o 19 a t0/ 8
BUIhDING ADDRESS:
/L /J I/-� Age SANITARY NO. APPLIC,ATI�SUBMITTAL CATI
O : 'S N E: N 'Ic-N.+�IC../U S L# VaJV1
G/{L{.�1(/ 1 s.�/ /�J`/♦� �{./'/� � a N/C CONTROL N
PH IINC: 1,vO - / //N • W
ARCHITECT'/ENGINEER {/ VV BULDING PERMIT INFO
aOZO
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Gan
C zy= LICENSED CONTRACTOR'S DEC[ARATION
y 1 hereby affirm that I un licensed under provisions of 9(commencing C�—� chapter f g ` Job Descripn n
F== with Section]oW)acDivision3oflM Businestaor Ro(u+iom Cade.andmyli«nn it w r•�/�� l /'� +O
�x d v in full force and effect. ��`QC�}•f� ���ryv g/ge��
-y re0 i linen«Clsu
Contractor
tr
3 LL y Dau T'S DELL
H LL O g ARCHITECTS DECLARATION
i.nhntandmyplmeelWlMaudnwhirrc«.f, �XT SNOf1,
=od
Uccmd Pfefeulonal
OWNER-BUILDER m the Com ION
1 hereby affirm Nn I un exempt from the fessommh License law f«the
fz-❑ following ons.permit
t ]on uo Business and professions Cade:Any city or county
pror1requiemnprone,re<aestheater,ntfmvccherend,mrtparany
eduraroma S Ft. Floor Area - Valuation
me a ix its tic anantt,dm require Ne eppliam fIX r ommaxa it lofile a t...i aw(Cha mmn tI'
But he it licensed pumoot m the of Division
3 the Conu«mfa Linen¢law(C oder r
(rotmrcamciog with Section]900)0!Division J ofNe Busineu and Profeuiom Code)or
that he is exempt therefrom and the basis for Ne alleged exemption.Any violation Ap WbOccupancy Type
Suwon 7031.5 by any applicant for•permit mbj«u the appliunuo a civil
.a more Nm five hundred dollars(5500).
I,as owner.(Ne propeny,mmy employ«a weed wegamtheir sole compenuum, Ired InSpectl S
will dome work,end the a.,.is no intendW IX offered for We(Sax.7044.Business
and Prufusimu Cade:The Convaclm's License law does are apply to an owner of
property who builds or improver Nemon,and who does such work himself or Brough
We own employees,provided But such intpovemenu an:no intended IX offered for
sale.H.howe er,the building or improvement is sold within one yemorcon,ledon,the
J
owner-builder will have the burden of proving that he did not build a improve for pur-
pose so
undo // _I
❑I. under of ci Sac.7 y,emdelusively. contracting,withrushed moscoton i- Q I�
csLa d pro)cm(ger.](Ha,Beninese and R.Pohdom Cade:)The Conheeon.and O
cause law .,frotapplyto jemownerof property who buildsaird'.0hscmdrac and i
who con rsfor each projuta with econuacmr(s)licen pursuenlmNe Cantrectofe 1
_ aMAR 2 2 2000
License
1 ea Sec. P for n
Ow« ells
WORKER'S COMPINSATI11IND.CIARATION
1 hereby affirm under penalty of perjury mme of the following declarations:
Ibaw.ml will maintaina Cediricare of Conssnuorelf-insurefor Workefs Compen. - -- -' '--
stairs,u provided fee by Section 3]00 of the labor Code,for the pedorma«e of the
work for which Nis permit is issued.
1 have and will maintain Worker's Compensation Insurance.as required!by Settled '
I WoIM labor Code,for the perfonna«emthe work for which this permit is issued.
My Workcr'a Compensation loormce cattier and Polley number me:
Carrier: Policy No.:
CERTIFICATE OF EKEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(This sectiam road ox Mcon deted lithe femur is r«mre hunNeddollnrs n lixi)
or los.)
I teddy that in the perfottdence of the work for which this pemut is issued.I shell
no employ any person in my mmror se,u to Mcome subject to the,WakenComper-
nronlawsofcarcomia.Date
Applicmt
NOTICE TO APPLICANT:If,of e,melting this Certificate of Exemption,you should
Moore,subjeO to IM Wokces Compensation provisions of the labor Cade,you must
forthwith comply with such provisions or this permit shall be d«md nevad.
CONSTRUCTION LENDING AGENCY
Q I hereby dorm tlw there is aconswdot lending agency for the perfumunce of
z the work for which this permit u issued(sec.3097,Civ.C.)
Fro Lendsla Name
> U=t's Address
W E 1«n,fy No I have red thus.ppliealice and rue Nn Brea ere lot...is
= z <ooect.l agree to comply with ell city and ronnty odinenc<s and r ¢laws relaun8 to
bm
UOlding continued..,and hrebyeilecau repreeenuives of this city to mrerupon the
above-mentioned potently for inspection purposes.
Lm F (We)rep«m reeve,indemnify and keep handless the City of Cu,.,..against
0 V Eebilities,jndgtronta,contend expenses which may in any way accmeagal sued City
} 0. in consequence of Bu 8fmtin8 of Nia permit. 1 9J ."70
� . O
f^ N AP'A ANT UNIIERS'I'ANDSAND WILI. 1'LY II ALLN(l,-W11NT
ARE
U ADGNg.
S� fApplic t/Gonlrm me
HAZARDOUS MATERIALS DISCLOSURE
Will Nc applicant or future buildingoccupant amu of hadle bamrdone materia Re-roofs
n defined by the Cupertino Municipal Core,Chapter 9.12,and the Hath and Sddy
Code,Sectio.255J2(a)P / Type of Roof
❑Yea 2
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hasard""rev conumim m;UudeB Nc Bry Arca Ah Quality Maragemem installed. If a roof is Installed without first obtaining an inspection
°" "' I a gee to remove all new materials for inspection. Applicant
❑Yes o
Ihaw r th haardousmateridercgnirementsmtderChapter 6.95ofthe Cai- un erstands and will comply with all non point source regulations.
tom' eelth&safety Core.Secuom 25505, l 255)0.I u tand Nal if Ne
pm' n doer nal msrrentlY have a term, y nsibild,._ i Ne asurant
the
Inerrant.whiC, Mnu. eo(aC ificet Occu
Signature of Applicant Date
o rodeo- agent pate _
All roof coverings to be Class"B"or better
OFFICE