00030205 CITY OF CUPERTINO - PERMITNO. _
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: b4D03t)a •S
BUILDINGADDRPSS:
�/ISANITARY NO. APPLICATION SUBMITTAL°ATI
4o/O 002! U E, fee VIL .Services C, _'i
OWNf:R'S AME: U
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PHON::: 7;)r • 1:1.
ARCHITECT/NGNEER
BULDING PERMIT INFO
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F i LICENSED CONTRACTOR'S DECLARATION
ozc lhenby.Irrrn Nu l.mlmemm lover pmdaimrt of chapter 9anmmeaing Job Description
Z4 l–w in force
effcDivision3of Ne Buaiassaad Pofnsiam Cede,em my liccnw is
�y"j in full force and cRal.
< Llre>veelan, C # �GYAe1G £ XIAIL 165 K A&LACCWaUT
3 LL U Date Contracm
H a O¢ ARCHI'IECrS RATION
v��,•J I undertuM mY I No ublic rcwms
5
to n< bored Pmfcu' tea
l3WNER�B DE an,CimTION
1 bene Ram Nal l am aempr ore the Cotion C s a Any c Law for the
followinghicunrest a(Section]031.5.Busircss aM Pmfns;ona Cade:Any city su county
which itsiss,neenrdtlaramtmctaac.;mpmve.demoRN,finwigrorrmlmale S Ft. Floor Area Valuation
3 petheiss issuance,asoregahe Novisioso for mchpemliuoflcu;aw(hmmem q'
-
(coheisingwi SmuammNepro Lvisi Sof CBn iw Licence law(Ch )er 9
06(commrca;egw;th Sccdon]000)tfDiais for ofd seegedcancadon,Anyovi Code)or APN Number Occupancy Type
Nat he is 31.5 b annfrom am the Mons ler the alleged ewmpdan.Any it Pentre of 541q7–,05-609
Section]031.5 by any applicmt for n perm;uubjecu the applicanuo a civil Penalty of
wi1 mom Nan live nuwm dollen(55001.
I.nowmm�rNe the situation, empen«awiowad:nNeiraaleeampemaea^, Required Inspections
will dothe work,and Coe: avectunisnet inLndortraw do, a1 (Sec.]BW,owaners
and property
w ions Cade:The over d lm'a, ndLicense Law does Iwt apply m if owner of
his o ny wW Wilds or improve Norton,euro who des a cooter steel or or Wd fee
his awn however.
Provided Nn such rent is sold w an nm imeador a offered fm
colt.If,howeverda Wilding or improvement iNethwithinoneildori prove fon.r pr,
comer-builder will Marc 0w burden of proving Net h did not build for improve for pur-
pose of ule.).
co I,ou tweet of the property am eaness,and
coatrwdng with l)TW Connector's
U. �t
c me La the es not (Ba.9swa,weer of and Property
who Wionslds
Code:)The es Cher lean.Lim o /
cense Law des^til apply to ts owner of pmpeny who Wilda n improves Nenon es /
who contramsfm aah pmjecu wiNecontaumAs)licensor WrtuarnmNe Continues '
License
p 1^m ners,under Sec. .B&P C for this canon V
Owner Dem
WORKER'S COMPENSATION DECLARATION
.� 1 hereby aftror under penalty of perjury,one of the following declaration:
and t
p 1 have win maintain aCen;fcaa em ofComto self-inum,Neworkees Core
mpe
sation.as provided for by Section 3700 of the Labor Cade,for the pecfocrneae of da
work for which this Permit is issued.
p 1 have and will maintain Worker's Compenumon Insurance,as rcquirtd by Smut,
3MMM]0���•••0of the Le otrynNcpmform wmkfm wrench this permimis;awed.
ompdnwtifon I n comm d y No,numbed art:
r hcy No.:
CE CA O^F 1 ION FROM WORKERS'
COMPENSATI INSURANCE
(This.weti eor not hctmpletm if Ne Permit is forme,hundrW"Into(SIM)
or less.)
1 ecnify that in Ne pcNow.aof the work for which this permit is issued,l shall
act employ any person m any manner an n to become subject m Ne Wurkms•Compen-
sation Laws of California.Dan
APplicanl
NOTICE TO APPLICANT:If,afar nuking this Candice.of Exemption,you shoed
become subject to the Workers Compensation provisions of the Labor Code.you must
fonhwid,comply with such Provisions or this permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
Q C) Ihnby alfnn[hm there is a conwmetion leading agency forth pccfunn^ne"a
the work for which Nis pcmril is lssum(Sec.3 hr?.Civ.Q -
F' Lenders Name
I Landi Addnsa
W 1 certify Nal l have nem this application and auto that the above iNolnution is
0a correct.l agree to comply with all city and roomy ordinances and sore laws rickamg to
G Z building conal^^.arta hereby authodc,mpreseoniva of this city to anal upon the
U Q i bovo-mmlianed property fm inspection Wryowa.
fsi F (We)agree to Rave,indemniry and keep harmless the City of Cupertino agesion
Q f, liabilities,judgranm,ruan end mesas wlikhmay in any way accede against said City
} W in coos Rae of the grentin9 of this ps n nit.
('a S APPLICANT UNDERSTANDS AND WILL COMPLY W1!1P ALI.NON-POINT
U zf&tfit�
'RCP !GUTATIONS.
fApplme murwlt! Deme
FIA RDOUS MATERIAI DISCLOSURE
lthe Mlmca^lorNmnWildingacupnlsmmorhw&ehaa ousmatedal Re-roofs
by Cupertino Mun' 9.13.Wthe HWN andStymy
i 25532(x)] C1 Type of Roof
❑Yes
Will the Indicator or future Wilding acapant use equipment or devices which All roofs shall be inspected prior to any roofing material being
rout Mrardoua am contamimna asdcfned Bay Area Air Quli[y,Management installed. If a roof is Installed without first obtaining an inspection
District] I agree to remove all new materials for inspection. Applicant
C]Y. No g
Ihave mad dohawdoua materials nquirtmenu under Clopus 6.95 of the Cali- Under reds and will comply with all non point source regulations.
forma Health&Safety CWC.Sections 25505.25533 and 2553x.1 undemumlthat'
Wilding dm no cuenndy have a mount lher It is my nspandbility w notify Ne upant
offt on,anmcnla which mum h mel prim m uaaae of a Gcmificaa of
Signature of A icant Date
em
Owr authonam agent Dam
All roof coverings to be Class`B"or better
OFFICE