00020183 CITY OF CUPERTINO
PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ` 0002 O �,3
BUILDING ADDRESS: \O O
SANITARY NO. APPLICATION SUBMnT4 DATE
IWNER'S NAME: LCL 1 ` C-L d0
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ARCHITECT/ENGINEEH _ /'4 f\ BULD GP[RMlfl
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UE3AC� P1tct�SaN
D LICENSED CONTRACTOR'S DECLARATION
o = I hereby a(Brm Nu 1 un liccnmd sada povisiom of Chaps 9(enmmeneing Job Description
-v:r J wiNSeclion 9000)ofDivision3aoffrN��e}Businen ad Rofesaiom(kCro/sryd�e.aM mY littn«is yyam"�/
'0 Fd Li eel forCcean <ReciC `V'r 1k.♦ "t�,tn kT'1 s-i 'Y` O �' D _// ��'�� /, /� y-� f\
L'ILL Dalt ar GOIIVBcbr
LL O¢ I understand my PI AR�lH hLus$edasECpublicAATIOrecor1ZkA\1+ , t�.I)Q 1M6uLi=- \-�J��(L�<[,N C� °j
v <�
>i Urinated PofeaelmW r
I-^_ OWNER-exempt fr DECLARATION -
1-Z a 1 hereby.(Sero onn 1 un exempt from the Contractor'sCal License Law for the l/.f•�
I x C following reason.(Section 7031.5.s.Buailar, and Professions Cede:Any city ar county
3 which requires issuance.permit m common,der,improve,hpermM,ar repair any tatemeexpanduet Sq. Ft. Floor Area Valuation
pnmtoiaensemonart to the previsions of for unci Licensle ae ned Law
+rJ
than he is licensed pmuenuo the previsions 3 odia fthee Best...
License law(Chaps 9 (�
thane a is exempt
ptthertion and of Division ofNeegedExe andon.Any
Cine)or APNNu r c ane e
Nat he is eaempl thsefmm and Nc bsis for the alleged Exemption.AnY violation of P Y�'P
Secdm 70313 by arty applicant for a permit subjects the applicant a civil penalty of 3 ( V
I more Nen five hundred dollars($500).
p
1,as osonr of the prepay",.or my employ«s with wages as their sole mmpewtian, R quired Inspections
will do tWwork,and the structure is nor intended or offered for We(Sec.7044.Businces
a and PPvfea moss Code:The Contractor's Lmans,taw docs m appy m an caner of
property who builds or improve.thereon,and who does such weak himulf or through
S his own employes,provided Nm Each irepmvemcna are nm intended se offered for
We.IL however.Nc building or improvement is and Within one year Of compleuan,the v
weer-Imucr will have th<buNen of proving that he did not build or improve for pan- -
pose of sale.).
[]1,as owner of the property,ant exclusively contrarting with licensed contractors to O D
construct the project(See 9044,Business and Professions Code:)The Contractor'a Li. V
.nae law does wt appy m an owner of properly who builds or improve.Merton.and �Ift�
sa wed commetsfor such pmjecls with a conuactor(s)licensed pursuant m the Conenclor's _ • AT? U p �}
a Licenu Law. Fe [tl60
I am exempt under Sec. .B&P C for this reason
water Data 8
WORKER'S COMPENSATION DECLARATION Yom`
I hereby affirm un4r penalty of perjury one of the,fallowing deelantiom:
El
(have end will meinuine Cenifcae of Consenuo ulGinsum for Workere Compen- —
motion,as provided for by Section 37W of the tabor Coda,for the performance of the —
ors for which Nis permit is issued. ff
I have and will maintain Worker's Compensation Insurance,u required by Section j,�t iJ 11 sail t-ins
'=
J7W of Ne labor Code,for the pertonnanm of Ne work far which Ni.permit is issued.
My Wurkera CompensationCERTIFICATE
Insurance
MEMmmd Policy number art: ����
Carrier: Policy No.:
CERTIFlC O OF COMPENSATION INSURANCE MOM AN W00.KERS'
COMPENSATIONINSURANCE t
(This senim needmhcompleteG i(Nc permit is fmone hundred dellen($100)
it
arlea11" POW E_[
1cc Nat in heperforreaamof Newmkforwh' ispermit is iswed,I shall r,,
not empl any pen in any eons eco m e. .ubjecn Wa Co n-
6a11
plic Y ate. 7
Leman TO APPI]e wiad If,co rmkmg is Ci,iim of of Bacmpi n,yo should
ha dwit vubjecl I. it Work ro Coins or this
pmvisions of the Labor Coke,you must
forthwith comply with such provision.or Nis pennil shall W demand rooked.
CONSTRUCITON LENDING AGENCY
Q I hereby affirm that th<uiaa conmmlthm ledingagency far the'fmrunce of
Z the work for which this permit u isaud(Sm.3097.Co,C.)
E-, L<dee:Name
a > LxWuEe Addrtu
fyjE I ceNfy clow 1 have red Nis application and as a Nm the aWvc information is
D. conal.I agree to comply with ell city ed county 0uhro ems and ams laws mleting to
•7 Z building connmction,and hamby amlwriu reprtamomVeS coins city to enter upon Ne
U 0 aWve-rrmuomd progeny for inspection ptepse es.
Liv Ew (We)agree to save,indemnify and keep harmless the City of Cupertino against
Q U liabilitiegjdgmems" sed apenus whI Ir manywa eagdmtsaid City
>1�a L,il incoSOTnuqucnce of ntingof Nispermit.
AI'pLICA Dy S'T'ANDS 'D WILLC PI 1'r11A .NON-IgINT
I.
igF.
namrtof ApplicarturCmi-clm Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture Wilding occupant store or handle hamme smannal Re-roofs
in defined by the Cupertino Municipal Code,Chapter 9.12,and the Heath and Safely
Coca,Section 25532(a)9 Type of Roof
❑Yes ❑No
Wll the applicmt or future Wilding accupam use equipment or devices Which All roofs shall be inspected prior to any roofing material being
emitha .saabeonaccimusasdefinedbyNrte
eBayAAirQualityManagement installed. If a roof is Installed without first obtaining an inspection
Diavict7 I a ree to remove all new materials for inspection. Applicant
❑Yea E]No
Ihave re.dNehatataaamatenal.no,immentsmichapter d.95ofthe Cali- un erstands and will comply with all non point source regulations.
fearda Health&Safety Code.Section 23N)5.25533 and 25534.1 understand that if use
building does carrenOy Mveetemnl,Mel it is mY ruPe 'NI yminify the occupant
of N s I rt< s to which moat be met guar vane- a Cenili<me of Oce y
Signature of Applicant Dale
D mer a
All roof coverings to be Class"B"or better
OFFICE