00040072 CITY OF CUPERTINO PERMRNO.
BUILDING DIVISION - PERMIT CONTRACTOR INFORMATION-
BUILIIINGADDRESS: /� I_ _ / ,J
SANTARY NO. APPLH ATION SUBMITTAL DATE
OWNER'S NAMEp
NIC CONTROL#00303
pHQ MSL G-12C' /M INA- q5-1-'Z3 °
ARCHITECIENGINEER BULDING PERMITINFO
two �KbS-- (7233
'93/ 38y3733
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F. LICENSED CONTRACTOR'S DECLARATION
z o — I hereby afrnhm nest I.m licmnad sorer ptovromm.f aupler 9(siting Job Description
G__w with Seclimi 7(XE fDivision 3 ofthe Business that professions Code,shat my license is
CYfJ in full forte acme cIT I�J /`Is/�/`� �j p� ��/mss
00w<O Dalc'cSm��Ca Iso . Y�//7UC U/—"1 '-"� rrL/
iii.c,�' ARCHITECTS DECLARATION I` { t �/
C_ S I understand my plans slat I be used u pubic«cards ✓�.
�r
a S ke-
limned Pmfeaioml
OWNER-BUILDER DECLARATION
C z a 1 hereby aR,m Nm at 1 aexempt from the Contstclors License Law for the
E F C following hoz (Section 703 L5.Bmimn W Nofassions Cade:My city m mumy
a which cocain...'morn to comruct.aha,,improsr,demolish,.1 meat,any,manor Sq. Ft. Floor Area Valuation
c. prior to its isauan«,alw rt pece.due applicant IDI such famous to Filet sipcd stttexm
Net he in licensed pursuant t.the provisions of the Conrracrors Li—law(CMptm 9
(commencing with Section 7000).f Division J ofthe Bmimu and profession.Code)m N r���� T{�er Occupancy Type
that the is exempt thmefrom ab the hmis for the alleged esemplian.My violation of a��� �'X •l'tQ Y
Section 7031.5 by any Applicant rot a pemuuubjeca Ute applicant to a civil penalty of eG! L AVKZ/
m mote Nen five hi rdrexi d.11.(15001.
1,mowamaflbepropenr.ormyemployees with wagmmlack ante campem,hian. Required Inspections
will do the work,And the structure is nm intended m oRcreel for sale(Sm.7060.Baeimu
tame prafessiom Code:The Contractor's Li«me law dors hrot apply toan owner of
propmy wbo builda car impmvaa thereon.mW who doe,sure work himself m tluough .
hisW own employees,pmddW that sack impt is cold a eR not intended nc oOerrW for
ower,oil a will
Wilding or imptoveovin it sold within on:year or impr plmior the
owmrboimecr will have tat boort,of moving that bo did not build m imptoss for part.
pt.,e of Ne.).
co 1. i ower of Ute Sm.7 ,am exclusively contracting with The c contnc e. to
onsirv,the emit,—,apply
W ss owner
of DIM.y othoom cis m imp....tromm. sad
or..law d«v ort apply to en owner of ptOptny wca builds ar improve,thereon,end
La (m such ptol«a rm(
who with acavacts),rensW Fontenot Ute Comrsrors
Lim". J
Liccnu Law. `
1 am exempt under 5«. .B R P C fm this reason
Owner Date O
WORKER'S COMPENSATION DECLARATION O
1 hereby affirm under penalty of perjury,aM of the following declantiom:
M Ih.vc.aW will meinuin.CenlRcate.f Comani to self-imuteforwarkCrsCompen-
sation,m provided fm by Section 3700 of the Labor Cade,fm the pctfmmeme of the
work for which this permit is issuml.
1 have and will meinlem Worber,Compensation Imminence.m m9vi,W by Section
3700of nee labor Code,For,the perfwmumm of tic work fm which this permit is issm"i
ca Workers r�pinpenSG;wWati4rp sr (�ehrim Andy,..:nat01�C I/�C"t/1
Carries •4'fi1 Y ATE OF Policy O�RS'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANC6
(This sectira rtemrtm lY eornpletM ifthc ptrrtut is for one hui.trcd ddlan(S,00)
or lest.)
I mnify that in the pe0onnemaof the work for which this Knout is issued,l shall
awl employ any person in any mmm,so as to M1orome sobj«t to the Workers'Compen.
which Laws of Celifomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you aboard
become subject ro Ne Workora Compematimi pmviskm,of the Labor Cade,you mol
forthwith comply with emh provisions m this permit,ball W decrrcd revoked.
CONSTRUCTION LENDING AGENCY
O Ihereby of.that dorm is a consruNan leraing agency for the pMomence or
rZ. ythe work fm which this permit is is,ued(Sec.3(197,Civ.C.)
Lender,Name
�( 7 IeidersAIdmst
WE 1 certify that L have read this ii,hcation and...that the above infomadon is
IL correct.I agree to comply wine ell city same many mcloomer same mm laws relating to
;D Z Wilding crosructi.n,aml hemby authorize mprtsenmives of this city%center upon Nc
U O .hive-mentioned ptapcny for inspection purposes.
Li F (We)agree in save.indemnity W keep harmhoa the City or Cupertino against
O f.7 Iiabnaue.,jadgmeme,evocator!expense which may in,ny wry--a agaimt said Ory
>. W in emnso mom of Ne gmnungu Ni,'omit.
L APPLICANM;1NIANDS. ND WILLCOMPI.Y WIlli ALLNON-POINT
/ 106
Aft
Signmurc of ''been Comn,m
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future budding occupant start m hanNe harandous material Re-roofs
m defimd by the Cupertino Municipal Cade.Chapter 9.12,anal the Healne and Safely Type of Roof
Cone,Section 25532(x)? ✓ yP '
[I Yes No
Will the omlicam at fumrt Wilding mcupoa uu equipment m devices which All roofs shall be inspected prior to any roofing material being
emit haermomis air comamimna as defnW by the Bay Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
I a tee to remove all new materials for inspection. Applicant
District?❑Yea 1 g
IhavcrtW materi .re,ainmensmtherChaptm695oftheCeii- understands and will comply with all non point source regulations.
au d.v
fanua Hut mmY Sections 2 50.5,255JJ and 25536.1 unhrsaM Nat if Nc
building dm mcu IIit ran.L .1i%it my responsibility to notify the occupanl
afnectequirem,a i ,t n o ro iaumce.fa Cenmf%c e
Signature of Applicant Date
owner or euNorizd teem ate
All roof coverings to be Class"B"or better
OFFICE