00050145 CITY OF CUPERTINO "`: PERMITNO.
d nUrr.DINcmVISION PERMIT CONTRAC`I'O 'INFORMAT QI N,: �� �a'j�5
' BUILDING ADDRCS' ,J
0 O �1 , O e /r �D SANI PARY NO. APPLICATION SUBMITTAL DAT
'41/z ° fv P b sv/Qs�t �/ 7 (P 5-,—(/t? rGy�(L
Ne CONTR LO M
RCHITEC`r/ENGINEER / BULDING I'sRM11 INFO
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u
F LICENSED CONIRACfOR'S DECLARATION
��=? l hereby affirm drat lam licensWuMu provisions.(Chapter 9(ce.nang Job Description f1
ami t- iniNSxrce and all Ai Sof dr Buv«saaMffofwion.+Sah.ammY license is ^�� � �J /'e /` C
��s< in full force eRttt. ��_ \r/-. 4 �� C' J
Date lasy� lic.a
x 3 a N Date S C DELI
r_C S ARCHITECTSS DECLARATION
yz<5 I underwnd my piw shall be umd u public mmwds
n c=z Licn«d prof<ssioml
v, OWNBR-BUILDER DEMRAnON
�Z r 1 hereby amnn that 1 am exempt from me Conuacto's License Law for the
Y o following mason.(Section 1031.5.Business and Profwions Code:Any city Or County
W 3._ which requires.Pensth m CosWct,alter,improve,demolish,or repur any structure Sq. Ft. Floor Area ���///al tiofi"a
ri
pm its iswence.also sequins fie, ic.nt foes«h permit to fit.a signadautcmcnt
that he is licensed Foresaw to use provisions of the Contractors License taw(Chapter 9 v
(commcncin6 with Section 7")Of Division 3 of the Business and Pridessi.Code)or
Wt he is exempt thererrom and me basir for me alleged exemption.Any violation of /AP Num3ber ClY q 0 0 2 Occupancy Type
Section 7031.5 by any appi eant for a pmnit subjects me applicant to a civil penalty of C9
«mere men five hundred dollar(5500).
I,a.nwnerarthrproperty.«my<mployecawimw.geasmeirroleeompesssti«. Required Inspections
woB dome work,aW the ewemrt is meet intendd«oRemd for Wc(Sec.]054,BuaCcss
and Professions code:The Co..,.i License law docs Iw apply ro an owner a
property who Wilds or improves demon.and who dots such week himself or through
his own employ«.,provided that such improves«nts art ow intended«oifored for
We If,however,me Wilding w improvementis sold within one year of completion,dte
r-wilder will have me author of pnovi.,met he did not Wild«improve for put-
you of sole^). /
is
❑stuas ow erofthe propertSec.7Ey.surn,Bsinesi and codentimr with 11c cormcmesd commurces t.
construct des wit (Sec.o an owner of
Professions code:1 The Cs demon.Li. l
w osc Law dots rot apply m ts with
a of onpeny who builds or iantto.<s Corton,and v
who contacts for such projeca with aconlracmn.p licensed pursuant m me Convacrore T
Li«nse law.
❑tum ex<mptunder Sec. .BAPCfarmis rtuan ✓ /1
Owner Data V
WORKER'S COMPENSATION DCCLARATION
I hereby affirm under mim]LY Of perjury one of the following dcclxwtmwt
]1 lowland will maintain aCenificatr of Consenuo rel&omuse for Worker's Comp<m
Pration.as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is iseod.
1 have and will maintain Wnhrrs COmpenution Insurance,in namird by Section
3700 of the Lear Code,for the performance of dre work for which Cis permit is issued.
My Wo t cer Compensation Insurance cannot and policy number ate:
Cartier: policy No.:
CERTIFICATE OF EKBMIxHON FROM WORKERS'
COMPENSATION INSURANCE
(This aeeri.need am be completed if the permit is for.«hundred dollen($10(1)
or less.)
I Crnffy Cut in me peAorma«< <work for ohichthiapermitisissued.lshul
not employ any persue is an aware Io owe a n .the Worten Compete
Zion La diff, 11 te
App icant
NO'i10EPL NT: rer :mg mi.Certificate of Exemption,you should
be:os«subject I me Wort s Compensation pmvisiom of the Labor Code,you must
foMwith comply wit such provisions or mos permit.hsdI W dicemd revoked.
CONS IJC`HON LENDING AGENCY
O 0 I hereby affirm that then is a comumanon lending agency for Ce performance of
z me work for which this permits issued(St 309].Civ.Cy
IedreC Name
} landcrs Address
fy 0 I candf,thin I have mad Cis application ad auto mal 0e all infomatinn la
0. contact.l agree to comply won all city and comm,odune
it <a and rote laws relsong to
Z Z building conmuction,and hereby authosixe rx,meanwives of this city tomer upon the
V O above-mendond prof eny for inspection purposes.
Gr. F", (W.)agree to save.indemnify harmlras dre City Of Culenimetagainst
O r,) liabihims,iu"irs.owns s��s ich may. yw. .c ru..gumtsem Cily
} !x7 u Ommagoc«eornrgransin it..
NAPPLICANT UNUf:R51' ,DWII r111A1.1. 'POINT
U Z SOURCB REGUTA 5
�v
Inatome of AppliCxnWon Data
HAZARDOUS MATERIALS DISCLOSURE
Will de applicant or form Wilding«cupim store or handle huadous material Re-roofs
as defined by the Cuperdnu Municipal Conc.Chapter 9.12,ad the Health and Safety Type of Roof
Code.S<Cdrn 2s533(a)] yP
❑Yes ❑No
Will to applicant or future building occupant use equipment or devices whim All roofs shall be inspected prior to any roofing material being
emit haaadom air<ommumarts n deflod by the Bay Area Air Qu.lity Management installed. If a roof is installed without first obtaining an inspection
District? Yea No [ agree to remove all new materials for inspection. Applicant
Tawe red the h.aaeamms mryd under
Chapter 6.95 of me Call. understands and will comply with all non point source regulations.
tomo Health A Safety ed 2550 and]3534.I understand that if vie
holden ...Co.d« eaten.. my responsibility a,notify to«Npam
Of int issoence Of.Cenlllcnle of(kcupwvY,
Signature of Applicant Date
nor ix nonad ager Date
All roof coverings to be Class"B"or better
OFFICE