00050082 CITY OF CUPERTINO - PERMIT No.Q
BUILDING DIVISION PERMIT CONTRACTOR•INFORMATION;:,, -00 U 0\
BUILDING ADDRESS:
��+ nc&I&L SANITARY NO. APPLICATION SUBMITTAL DAT
O '—'S NAME: t I �M�L,�V/C� i/{.9A —/,,7
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ANCHyr:CT/ENGINEI3R / - /, BULDINgG/PERMIT
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F<V LICENSED CONDUCTOR'S DECLARATION
z0 Oz v I hereby arra that 1 ant licensed mtla pmviaiona of Chapter 9(wmmencing Job Description
(_w with Section 7")of Division 3ofthns and!e Business and Profession;Code.a
my license is 5 l2 ))���� ��//''
Y j in fallearand ClfecL �
Ote c.U liceese Class Con
LL N Dam Con DEC VST , .,..,^—
F u.O ARCHITECTS DECLARATION TYJT���J
to
I undershnd my plans shall W uxd as public reemds
Ci 9t IL W 11'tiW�—P �IKTN J
n,ce Insured Professional
OWNER-BUILDER DECLARATION
Z a 1 bereby affirm tut 1 am exempt from Ne Contractors License Law for the is
5 z p foiloor ng reason.(Section 703 1.3,Business W ssions ProfeCode:Any city or county
w C whim requires.pemhit to.."m alum,improv.,demolish,or repair any swctum S Ft. Floor Area UltlOn
prior to its ismana.alio requites me applicant foreuch reason to file a signed statement q'
tut he is licensed pursuant to the provinces of Na Commcuo/a Licarm Law(Chapter 9
(commencing with Smtion9000)of Division 3 of the Business and Professions Code)or Number OcecCCCu an T e
Net he is attempt dmrefmm W ton buts for the alleged eamption.Any victim.of Q l AP T� -_ YP
Section 7031.5 by any epIfirson fm.permit subjects the applicant to•civil penalty of 'L
rot more tun five handled dollen(55001.
❑I.ax..r of the pmopeny.ommy employees with wagca ss dclu lel-compemuies. Required ections
will do the work,and me structure is out intended or offered for sale(Sm.7W.Business
and professions Cade:The Connector's Liana Law does nm apply to em owner of
property who builds or improves thereon,and who does such work himself or through
his own employees,Provided mat such improvements am not included or offered for
We.If,--udder will have
ftgorim a presmithat did
net ne
year ofcomple for the
owneo Wilder will love the WNen of proving Net he did not W ild m impavc for pur-
pose a(ale.).
❑I,u t the prof ct pm.704 .B ll.,v oil convecting with littnseCommute. to
L.-
exam
La the does
apply
o an Business and ny wh mnsWild*
d*or i Thepro Connacurs oi-
unse law does nut apply je is owner of property who Wilds m improves thereon,and
whoconUacts fm such pojects with ac.npvcmr(sl licensed punuahht to me connector,
License Law.
❑lam exempt under 5m. ,B&PCfor mix reach S/
OwnerDate
M �q
WORKER'S COMPENSATION DECLARATION
ms
I hereby arms under Emalty of peons of of the following dmlarens
to :
1 have end will maintain a Certifium cf Ce..1.self-imme fm WodehCompen-
sat.on,as provided for by Section 37M of me Labor Code,for the performance of the _
work for which this permih is issued.
1 have and will minimum Weida Compunation Insurance,m anuird by Section
37W.f th.father Cade,for ton perfermvrRe of the work for which this permit is issued.
My Wurr�c�kcp �eh�e�y�wer and Policy nit
W.
r 4 11 1 Policy No: =1 SnI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nmtl not W completed if Ne permit is foronehu baxi dollen(3100)
or Ica.)
I maify Nat in me performance of dm work for which this permit is issued,l tall
not employ any person in any manner as as tobecome subject to the waters'Compen-
sation Laws of C.lifomData
Da
Applicant
NOTICE TO APPLICANT:If,after making this Cenificatc of Ex mptlon.yen should
become a dject m the W.hers Compenurion proomom of the Labs Cade.You must
forthwith comply with such provisions in Nis permit shall W deemed revoked.
CONMUC ION LENDING AGENCY
I hereby M.met them is a wnnroctimi lording agency fonhe pmfmtnatae of
Z the work for which this p.it is issued(Sec.3097,Civ.C.)
re„ h Lmi Name
Lender's Address
— 1 certify that i have mud this npplicalmn and aunt mat the above information is
CL. 42 correct.I agree to comply with ell city atl cwmy ordinances vb sum laws calming to
p Z Wilding cmar ctiom and hrmy autwsice temesentaives of Ws city to anter upon the
V above-mentioned property for inspection purposes.
Ls. F (We)agree to save,indemnify tend kap bamless die City of Cupertino ammin
�1
liabilities,judgmental,touts and expenses which may in any way amroe against mid City
} {yj in consequence of the granting of dur parmn.
H a APPLICANT UNDERSTANDS AND WI 1.1,COM PLY WITH AL1.NON-POIN"1'
(..3 Z SOUNCR REGULATIONS. l I�
hgnature of App uantyConnactm Ddre
HAZARDOUS MATERIALS DISCLOSURE
Will the applicantor future Wilding occupant stmt or handle hauNdu material Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12•and the Heald and Safety Type of Roof
Cede,Section 25532(.)7 yP
❑Yes ❑No
Will the applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
mit hmad.us.ir conWrommis a deflned by the Bay Arca Ah Quality Management installed. If a roof is installed without first obtaining an inspection
d t7 Yes ❑No I agree to remove all new materials for inspection. Applicant
I have and the baaatdous material.mewisions under Chapter 6.95 of me Cali- understands and will comply with all non point source regulations.
forma Health B Safety Code.Sections 235115.25533 and 23530.l mv4 stand that if to /�
building does no currently have a rentor,that it is my responsibility u notify a cupann 4�(t/
of m m rgr�i �env whim mu t be t prior to issumee of.ce " of O uppp�yw. I
Signature Jof Applicant Date
no or and oriaed agent Date
All roof coverings to be Class`B"or better
OFFICE