00050005 CITY OF CUPERTINO PeRMIr No.
BUILDING DIVISION PERMIT CONTRACTOR IN'FORMAT;ION: C?00S
BUIIAINGADDRESS:
SANITARY NO. APPLICAUON41JBMITTALDATE
2 00
OWNCR'S NA E:
NIC CONTROL
PIION{C: ❑
OTE - e
ARCHITECT/ENGINEER fes. BUTAING PERhI1TINFO � '"
�O0 a
v¢d
r y i LICENSED CONTRACTOR'S DECLARATION
z.O m— I herby affirm that 1 am licensed under provisions of Chapter 9(commencing Job DBSCrIpl100
=tw wiNSactbn)0110)of Divuton3ofde BuslmasatM faom Cade•mdmyhecnmis
In full tone and effect. -, 1
r K d 6 Licari:CTaxs LiC.N `�`\I✓, • , OI
LL 3 LL y DaIC f.'pnaaCbr
C:O ARCHITECTS DECLARATION
1 rdertmod mY Plans sh,ll he uuI sa public rccoda
2 a O O Limserd Korea imul
v ucS o N OWNER-BUILDER DECLARATION
I Z- 1 hareby af0rm that I am exempt from the Contractors License Law fee the
D following mama.(Section Toa L5.B,warn. and�uiom Cade:Any ciry st roune,
a3°Owhich requires a pemrt re construct,ilia,improve,h permit or npsigany swoon S FL Floor Area Valuation
priormits cnued patmrt 1.ilm prevision Of for soonpamdtwfiles Law(wtemcm q' w�d
toommee licensed punumt wsne provision of she e,BumlMe Wcennlsw(Consul r al b OHO :
(cot he is
gwllh Sauon'mool of haps f rth al Budcesaaadon Any
Consul or A N Numb Occupancy Type
Wt he is 31.5 b duarefoun
apf aut Ne bsais for the va the exemption to Any violaum of �j / �x
Serum)8315 by any applicant for•permit subjau the applicant to•civil perslry of V[ f/l��'s U
nm mon Nan Eve hundred dolls.(tyripl
❑L a the
r of din pmpeny.m ter emplended or h..'esrd for We(ole cemPem•na, Required Inspections
will da,pe ra wmk,ad the mucron mit not intended m Law
doctor wla(Sm.1.an Rustiness
and property
who b Code:The C es thereon.
License Law dw ted apply se lf owrcr of
propw y mplbuild,pr improves tncnoq ad who dos such ooh hied or or through
his own employare provided r r wen mentis sold art ata irtedd a oBerd for
�le.IL however.Nc WildinH m impovemem is mold within nate yw of compleua,de O
owner-build,will love de bonder of pmNIws
vin, at M did Wild m improve far fm � tn�J
par- 'c : +
post of We.l. 1I e
in
❑I,as owner of the property,sum emlualwly contracting with Iremd contractors to
construct the project(Sec.70,14,Business and Professions Code)The Contractors Li-
wenn law don rte applyje ta owner of property who sedG or impto the
Ihem sac and /� I 1
who contracts s r such Out apply
with a contractors)propety who
pursuant to the Came,,and �11"l_J (�j,In[/,51,
L a Law.
1 exempt under Sm. .B At P C for this on
Dun,&
Z•?�C17
WOO RKER'S COMPENSATION DECLARATION
1 hereby iti munderpantry oeperjury oneor the following woAer'tiom: /vw
❑I has ad willl for byte a tion 37M of the at oCodensurt a oohed Compen-
wodsf as rproh thi for mi Ss iiuw 3)00 of the Labor Code,fm the pcHomuna of the !//
oh fa which this permit is iw d.
❑1 have and will maintain Worker's Compensation oftthw Insurance,b ma permitedl Sunted O/
My We Nc Isom Code,for Jct use mt me of d ooh for which dtis permit u mood.
My carrier.
s Compensation lexurmtt cerria and Policy rumba ace:
Carrico Policy No:
CERTIFICATE OF FROM WORKERS'
COMPENSATIOSATIO INSN INSURANCE
(This wctinn rad not hecompletd ifthe permit is loroa hundred ddlus(5100)
Or less.)
1 certify Out in she per minam anfsbe work for which this permit is issued,l end]
me cmplvy my person in my manor so as to become whim,on the Wuhan'Comp:r-
W ou saws of California.Data
Applicant
NOTICE TO APPLICANT.If,after coding this Certificate of Exemption•you should
Worene subject to the Woroces Compensation provisions of Ne Labor Code,you must
forthwith comply wit,such provisions ar this permit shall W domed revokd.
CONSTRUCTION LENDING AGENCY
Q O IhertbY aRsm Nos Ncrt isacaswNonkding:gam,for th:parfom roof
z the work I.,which Nis pesmis is isoed(Sec.3W7.Civ.C.)
r— — Lech:Name
a ✓ Lenders Addeo,
W4 1 writ,that 1 have read this application and sone that Ne above information is
A. z 10.1.I agree to comply with all city and county ordinances sd sum laws misting m
= 7 Wilding construction•and hereby oratorio rtpmee paives of this city tomer upon the
I..1 nWve-marooned Farm,for irommum pu".,.
tr. I;. (We)agree to save.indemnify and kap batmlew the City of Cupertino again,
0 V liabilitiesjudgmmu,cru ad:.penes which may in my way aaneagdnst said City
} fa7
I.con.queme of the&.ming of this perms.
[+ A P. 'ANT UND RST I IS AND WI IL COMPLY WITH ALL.NON-DINT
U z s II
BRIT 10
Si atunuf App cm Comnnm LDate
ALIRDOUS MATERIALS DISCLOSURE
WII Nes I rmmfmurt Wilding acuWmstme orhmdle harardau maserid Rero
- ofs
.,norma by Ne Fran.Municipal Code,Chapter 9.12,wall the Heels.ed Safety Type of Roof
Cdr.Sarson 25532007 yP
oYei Wit
Will the applicant or future Wilding occupant use equipment or devicm which All roofs shall be inspected prior to any roofing material being.
coot hawdousairmemmianu exdefindbythe BayAms AnQmliryManagement installed. If a roof is Installed without first obtaining an inspection
District? I agree to remove all new materials for inspection. Applicant
❑Yes XX o
lhave read de,hiconcl us tratmsls rtquinmena under Chapter 695 ofda,Cal4 un erstands and will comply with all non point source regulations.
forma Hcdd,&Safety Code.Section 25505,25533 and 25530.I understand thus if the
t dasnet c� dy M1avcateanr,Ow itis my rtspumibiliry to ratify Ne ouvpmt
th s -h must hemet prim'.iswarce ofa Can't, fQm, y.
e Signature of Applicant Date
trod d da&ant
Data
All roof coverings to be Class"B"or better
OFFICE