00040182 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR`.INEORMAT.ION: (7�0 PERMRNO.
BUILDINGADDRFSS:
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Pe,,( Fir CA—, SANITARY NO. APPLICA N U AT
O NF.R'S NAME: ' / f''y (� (tA yn,�1����
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y�f�l V •"cam N V • /' / / BULDING PERM11 INFO
ARCHITECT-64NEER — — 17
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LICENSED[ONTRACIOR'S DECLARATION
z o y� 1 hertby aRnm Ilial 1 am licamed under provisions of Chapter 9(commaneing Job Description
sem with Sation 1000)of Divizin Sof Ne BusinenaM Rofwiom Code.aod my lianseis
Jam'(— —`
=YtJ in fYll(OICeaM YOS 11 I�
p w u IlcmI" Ins _ Lie.x / //� 4 ('AV,
Ij LL y DetC '. LIJVL
ARCHITECTS Decl.Annn V
z�¢5 I underSlend mY Pla^a shut d used o Wblic records
a iv c Licensed Professioml
OWNER-BUILDER DECLARATION
t x> 1 hereby.Rrtn Nat 1.m exempt from the Convactds License law for the
I x O following ream..(section W31,5.Business end Ptnfwi«u Code:Any city«nuntY
d s
is ta9uins a permit to comuuct,alter,improve.demolish,or npur any SWtnne Sq. Ft. Floor Area Valuation
prior to its isms.,use sequins the applicant f«such pemut to flee Signed natemant
that he is licensed pmuam to the Provisions st the Connactda License Law(Chapter9
(commencing with Section 1000)0!Division 3ofute Buunen and Profwiom Coda)or
NAPN Number Occupancy Type
al he is exempt therefrom and the basis for the alleged exemption,Any violation of P Y YP
Section 9031.5 by any applicant fora permit bj..the applicml Io a civil pnalty of _ Q S Q
rot more Nm Eve hundred dollars(SW).
I,as owner of the property.«in,employees with w.gn o their mlecompeneation, Required Inspections
will de,the work,and the svucmre is ons imcndcd or ofremel for We(See.0014.Business
and Professions Cade:The Contractor's License Law don not apply to an owner of
properly who Wilde or improves thereon,and who does such work himself or through
his own employees,provided tMI such imparmertsmes are not rounded or offered for -
zale.If,however,the building or improvement is Sold within one year of complain,the
powrbu0der will have she burden of proving that he did not Wild or improve for Wr-
saMSale,h
L o owner of the property.am exclusively commatime with Bcensd comecton to
comm athe Project(Serao an eminefssedprofessions Code:)The
ers chect«s cod /
c ase law aa.nm.pply m an ith nor or property who bullas a and ova thereon,ora /
whomnaaw.f«such projau with a conuacmrts)licensed pursom m the Conoacmr s
0 1 W law.
❑1 am exempt uMer SM. .B It P C for this reason !�
Owner
WORKER'S COMPENSATION DECUBATION
1 hereby affirm under penally of perjury one of the following deemosince,
sat❑Iheve and will for
rte Section
of CovmuoCod insurtfor WoheM1 Co of the
work,as Provided for by Section 3100 of the Labor Cada,for IW Wdomupe of the
work which Nis .it is issued
❑1 have and!will maintain Workeh Compensation wink
whi h required by Section
my ethe Labor Code,for the prtormancIofthewort far which this permit is issued.
MY Woyp Comvcati nsV/F ecc cyrin and Policy n m
Comer vI'Ar
Policy O L✓
CERTIFlC COMPENSATION
ATIONMPTI N FAA ORKFRS'
COMPENSATION INSURANCE
(This session need not M completed if the permit ie loronc hundred dollen($100)
or ba.)
1 certify that in the performma of this,work for which this permit is issued,I sort
not employ any prison in any manner m as to bacume subject to the Wortan'Compen-
sation laws of California.Dale
Applicant
NOTICE TO APPLICANT:If,after inking Nis CeniEcam of Exemption,you Should
ovesom sidu*'m the Workrle Compensation provisions of the labor Code,You nun
forthwith comply with such provisions or Ibis permit shall b4 deemed invoked
CONSTRUCTION LENDING AGENCY
Q I hereby affirm that there is a connmcuon lending agency for the performance of
z ^ the work for which this permit is issued(See.3091,Co.C.)
leoders Name
a, 7 Lenders Address
Gti 1 certify then 1 have rod dere application and sere that the above information is
10, '�' correct.I agree to comply with all city and county ordinances anal State laws relating to
= z building comuucoon.and hereby amounts,representatives of this city to enter upon the
V O eWvc-examio«d popery for iapatin purposes.
W. F., (We)agree to nave,indemnify and kap barmleas the City of Cott n s.against
C) iL) Imbilam.,.jdgmama,cnu and expenses whichmey in any way accme agumt Said City
y (gi in Co.".,.of the grenung of Nis
F" mi
C6 STANDS
[AYLI'I'HALLNON POINT
SOURCE REGUI
SiBnatan IicanV room Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant tore or handle luaardous mmdal Re-roofs
as defined by the Cnpcnin0 Municipal Cade,Chapter 9.12.end the Health and Safety Type of Roof
Codes Sc ion 255321ay/ YP
0Yes nNo
Will meappliemtorfuture Wilding«rupmlasoMitipmenlar&vice,which All roofs shall be inspected prior to any roofing material being
emit havrdousa conumlmntaa%deflrtd by the Bay Area An Quality Management installed. If a roof is installed without first obtaining an inspection
District? Yes nNo I agree to remove all new materials for inspection. Applicant
li.a rand h.,dn amaeraare9aimmm n d Chapter b95a uh,Cali- understands and will comply with all non point source regulations.
forma Health&Safety Cade,Sections 25505,35533 and 25534.I udetsuM then if the
building docs not currently have a tewnl,Nm it is my responsibility to notify the«"pant
of the tryuimmenu which must W me pnm to issuance of a Certificate of Occupancy.
II{ Signature of Applicant Date
Owner or euthonzed agent Date
All roof coverings to be Class"B"or better
OFFICE