06100106 CITY of curExTlvo PERMIT C�NTRAGTOR INFORMATION
BUILDING DIVISION a.
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BUILDI��DpRE 1 �1 ��l/f g I•� �O� VAI PERMA, V . I OV"
OWNER'SNAME:
SANITARY NO. CONTROL NO.
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ARCHRECTENGINEER: /a,I ref BUILDING PERMIT INFO
a�11 fWa/VVt BLDG ELECT PLUMB MECH
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a j LICENSED CONTRACTOR'S DECLARATION
he C 1 kmby affirm Ws l am limned under prowk o
iof Chapter 9(commencing Job Description
;zw w'ith Suction JOfXI)of0ivision Sof the easier`.and Professions Codc.and myliccnsa is I — ^/�• �� �I O
; ? L,.',n Tartu anti, m Dff i1 5 ri r� I Ot ri o�
Liccnm y _ L'm.g
Date Cantrazmf
ITI -
ARCHECrS DECLARATION r r(r�w ••.agg•��� ;�,- �.a�/� , /1< 1 undersand my plans shall k used a Puhlic rtcords V N /�, ,/
r
ray Licevcd Proposal anal
1 OWNEm exempt
DECLARATION
f C 0 I hereby.sect thin 1 1. ,Bumps from the Contractors Co e:Any c law for the
:O o which ng mason.(Saito 703 1.5,Business andProfessions
improve.
d'nv Code:Any oily or county
which mquima n permit re chew t.akr,'nt for such
demolisht or repair ed umm ono
lost he its i licensed
also requires Novisio s of far such Potmit m file a noose,signed
2I-< (comme liavm Psectiot to the of Division 3thehe B uacmr And Pram law(C Code)
Sq.FI. Floor Area Valuation
«C (commencing he is xempt t Scction7000)ai Division of N,Businesampt Professions Cada)or
a�� that k u exempt tkscfrom and the bais for the alleged exemption.Any violation of
Section 7031.5 by any applicant Ter a permit subjects the applkanuo a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(MM).
1,As owner ofthe property,a ha employees win wages As their sola eompensation,
will An nc work and theme mese is nos inrendad m arfemA for,ak(Sec.7014.Busimss
and Profassioes Cmc:The Contractor,License taw does not apply to an owrer of Required Inspections
property who Wilds orimproves nonan,and whodoes.such work himselfor through his
awn employees,provided that such improvements are Amt horehound ornResm far ale.H,
however,the building or improvement is mid within oar year o(complcdon,the owner,
builder will haus nun buNen of proving that k did ret Wild or improve for purpose of
cale.l.
❑1,as,owner of nun property,am exclusively conuatning wide licensed conuaetors to -
construct the projcm(Sue 7044.Business and Professions Cade:)The Commences Li.
cense Law does not apply As an owner of property who Wilds or improves thereon,and.
who contracts for such pro3eets with a contractors)licensed pursuant to the Contractors
License Law.
I am exempt undo Sec .B h P C for this moan
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declaration:
hove and will maintain a Certificate of Covent to self-inmre for Worker'sCompen-
Amon,a providad for by Section 3700 or rte Lamer code,for the perromance of the
work for which this permit is issued.
❑1 have and will maintain Warkers Compensation insurance,As mgaired by Section
370!1 of rte labor Codc,for Ne pat(armmce of the.,it for which this permit is issued.
My Wor rs Compen,ation Ivuaance artiv am Po my number am:
comm �'1�1i3myN..: WLM'153070�
CO
CERTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu sce irm mead not W compk¢d time permit is for one hundred daliara(SIM)
or Ica.)
1 ccrtifv that in the Performance of the work for which this ficrnit is issued.I shall not
employ any pctmn in any manners,As to become mbject to the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If.after making this CeNficale of Exemption,you should
become subject to the Workers Compevadon previsions of the labor Code.you mon
.J Q fornwin comply with such Provisions or this Permit shall be domed md.
vnke
ZN CONSTRUCTION LENDING AGENCY
[-+ Ihereby affirm Wt nem isacenswctinn lending agency for rte Performance of
6i the work for which Nis permit is issued(Sec.3097,Civ,C.)
W� Landers Name
Z Lenders Addrass
U 0 1 certify that 1 have mad this application am sate that the above information is
correct.1 agree to comply with all city and county on inamen and sate laws relating to
.0U Wilding cansuumion,and hereby aumome mprnenativ of this city to enter uPmn the
.Wvc.mentioned Property for i a"hioa purposes.
H6. (We)agree to ave.indemnify and keep harmless the City ser Cupertino agatost
rq liabilities,judgments,costs and expcmcs which may in any way accrue against said City
U z APPLICANTaUNDERSTANDS AND alibis
WILLWILL COMPLY WITH ALL NON-POINT Issued by: Date Z_—'/
SOURCE R UCAiYOryST—�
ICIAfY t 1Z-19•o6 Re-roofs
Srgwu�c of Applic vector Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Willy the
Capmt ser fMuni building a oupsmason,Chmpm,9.1 or hurdle h Health A material
C deRnm by the Cupertino Municipal Codc,Chapter 9.13.and the Health and Safep
Code.Section 25532(a)7 All roofs shall be inspected nor to an roofing material beim
❑res +a P P � Y g g installed.
pi" Will the applicant of future building occupant use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
t hvardnv air canaminanss a defined by the Bay Area All Quality Management all new materials for inspection.
utell
❑Yu
1 have mad Ne hvattlsassmamfials resryimrrcw underCkPmrh.95 of rte Cali(oo
nix Health h Safety Coda.Suctions 25505,25533 and 25534.1 undersand thmif the Wide,
does not Currently have a tenant,that it is my responsibility to nmify theoeeupme of the
req ireac ss wita Certificate of Occupancy.
Signature of Applicant Dale
owner6r aanore.ea sem DateAll roof coverings to be Class "B"or better