00030098 CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT ^ CONTRACTOR INFORMATION: �/'�)1/�f
BUILDINGADDRESS: - �/ V V 0 0 o
' L� \ 1 Vo <•.1 (7� SANITARY NO. - APPLICATION SUBMITTAL DATE
I _ 38�� A.,.V.�l _ e�� _ -�.A1 N'CC CONTROI.x "
-Wit OwAmj�M_Q)n1Q 11710
Sd�►S,Q CA 9'V1 ).
<GIITtECT/ENGINEER - BOLDING PERMIT INFO
•a00 ,
't- LICENSED CONTRACTOR'S DECLARATION
Zv,—p I hereby'a1Emm tut l am licensed under pmvirions of Cheper 9(=ontmenging .Job Description -
r'.u, Q witSection 900a0r)o�f�°ivision3of Ne Businerr and RofcniomCWe,aM mYli<ense is Z•
5 Y '� in full force
tae.
tare yea x '
ToSDECr - -
TION
�LL Q� '• I understand my plains lllIfh ussed asp public icrecords //J /Q /[�/,• /,//�' /Ly)�/��/�/J
n•ic m� Licensed professional
m ,� '
— OWNERBUILOER DECLARATION
t_Z Q , 1 hereby affsm Nat 1 am exempt from to Contraction's License Law for the '
a following reams(Smtkm 9031.5.Business and Professiuv Coda:Any city or county
. 3 m which requires is perm,to cwowct,alter.impreve,demolish,of upnir any somcmre 'Sq. Ft. Floor Area Valuation
pow to its issuance,also trquire flit applicant for such pemd°d file a signed statement
Nm he is hc<med Wnunt to to previilotn of Ne Connowmra License Law(Cheprer 9 -S- a, OO
Idommencing wit Serelan 9000)of Dlvieion J oftc Bmimu and Profeuiom Code)or ,
t he is exempt therefrom ala to besie for tae.negd exemption.Any violation of PN Nul er Occur❑f ncy Type
w
Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3' �_� i4l O assjC I -- -
rwt.dearefiv.Workeddollua(5500). 1..��e/�r�/TT'lll
❑I,.owner of the property,or my employers with wages as Neirmle compewuaa, • Required Inspections
willdede,work,sad the structure is not intended or oRemd for sale(See.7W.Business - -
and Professions Cade:The Contractor's License law does rot apply to an owner of
pmpmy who Wilde or improves thereon,and who doer such work himself or through '
his we employers,provided Nat such improvements are not boosted or mrseri -
ule lf,Wwevw,Ne building car improvemem is mid within one yeas(compleuog die ,
nen Wilder will Won the Wooden of proving that he did not build or improve Torpor,
pose of rethe.
I,as owner of the property;i e exclusively convacung wit licensed contractors;to '
ler ,La toesnod (Ser.oan ownBuser
os.endn,fersdonawho Wilds
Code*Tor Comerism, nd
Li-
center Lawdwrrsuch Yeas ownerm property who Wdpurs imp to the thereon,and
who contracts faraucM1 projerb with a eontracmrfU licensed pursuant to the Convmtots
License law. - �0 •,
❑lamcamprde
eunrSec. ,Bk PCfw Nis rtuan - '
Owner one
WORRF.R'S COMPENSATION DECLARATION t -
i hereby afflim under,penalty of prijur,one Union following declandicau f - ,
)J lhuveandwillntaintuneCenifcate of Cowenuo sel4inmrefor Workers Comprm ~��""""`++r -
tion,as provided for by Section 3900 of the Labor Cade,for the proomtance of the - ..
k for which this person is issued. - y
aCat7 have and will maintain WnrYch Compensation Insurance,as reamed 6 Section 'lIIIJJJI/) _
ofthe WrCde,fw the performmce oftbe work for wM1ich Nia permit is issued.
M:We Cw pnwfmnlnrn ere poitPokynr p I ic,No MAR 15 2000
CER QgCATE OF E%P,MP'110NFROM ORKF,RS' .
COMPENSATION INSURANCE _
(Thiseectinnnerd not becompleted ifthe pemut is Troost hundred dollenDIM)
y�^�
Icenify Nat in many manner of the wohfw which this permit is irsuCorepall —+�„_� - -
non employ any person in any manner so as to become subject to the WorkerR Comprd- x
satiAwart-of California.Date -
Applicant - -
NOTICE TO APPLICANT.If.after making this Certificate of Exemption,yon should - t
,ernes subject re to Wwkefa Compenuuon provisions of the Ladner Code,you must
forthwith comply wit such potsomm or Nis permit shall be deemed revdted. - I
sCONSTRUCTION LENDING AGENCY n '
' Q Q I bcecby inn tat tem is a constriction lending agency for prrmmtt
Porof t
V] ate wkf h htn permit is isvud(Sec:J099,Civ.CJ
F,t .y Lcnd Name - i
a >:
Lero ea Address
WIcenify that 1 have read to appliotion and state Ron tthe above information is -
z cottect.l agree to comply with all city small coney ordinances and state laws melsuhg to '
U Cbuilding construction,and hereby Widener representatives ofthis city to mer upon me ,
above-norm and property for inrpec4rn putpeses.
0 [�. (We)agree to end save.indemnify keep harmless to City of Cuprmutm against - '
U liabilities.judgm<nts costs and expense.which may in any w.y..rw,.,xno said City u
•.thy�.a W .in consequence of the granting of this pemdr
L N APPLICANT UNDERSTANDS AND WILT.COMPLY WITH A I.I.NONd`OIN9' ,
U tA SOURCE REGULATIONS.
I
Signeemof Applicmt1Contosmr 'Date QLl L
HAZARDOUS MATERIALS DISCLOSURE ' (/II
Will theapplicancor future Wilding wxapant num or handle haeadous matenal RelooK, -
as defined by to Cupertino Municipal Code,Chapmr 9.12,and to Health and Safety -
Code.Seenor2553200? Type of Roof .
C3 No
Xie applicbntdr future Wilding occupant use equipment or devices which All roofs shall be inspected prior to anroofing material being
rrunt hsu dans v<9nu eros ae defmd by to Bay Are.AirD elitybanagem at ;installed. If a roof is Installed without, irst obtaining an inspection
°''"`° I agree to remove all new materials for inspection. Applicant
I have read the it in mammals exrireinents under Chapter 6.95 of tc Clli- ` un ds and wmply-with all non point source regulations.
form Safety Cpp have
Sectic door
i is and 25514.I understand that ifthe
.. `
F' reg doe- oris thin
love Wt itis responsibility lily mnwifY to occupant
to req' rrnnv hm trm ow thou else
Dwnerwaumori edzgent / Date Signature of Applicant Date
All roof coverings to be Class"B:'or better
OFFICE
r