00040102 CITY OF CUPERTINO /�� , - rERMIT rvo. J
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BDO\J LI
' IIILDINGADDRB55: .�.^} 1 "O� 411
' \ 'INQ,I SANITA RY NO. AI'YLICATION gUBMITTAL DAT[
�� ruLg 2r IAv�t� 1 .73 H 1 -1 /� N g
O NAM b 1^ l�th'C_
Q N, (\ .� � - NIC CONTROLN
7C,6H
NE. / 1cic / Ti[� " — BIJLDINOI'IeIiMTINI'OQ EW 6366
'I iC'I'l1iNGINEER ` - f / w 1 g"�t�+ 6Ya3ay VANLICENSED CONTRACTORS DECLARATION
hreby affirmNeif am licensed ndc pr 'eo sof Chaptei 9(comms tingJob Descrl tionSluande)ofDinuon3ofNeBunnea andProfess aMmYhameiaY ll i.e.«alld enter �//y/u� .f1
M.z w U 'License Clw�Idc.g \ 1,, i` ��k s',` n W QV✓1�4 QI
3 a y Deu—�.C_conDECL 111 1/�Iq\ 1 ( tj
O¢J ARCHITECT'S DECLARA ON 1 1 e \ CJ•LQtf\Cj,
I undersand mY Plans shall W used u Public records. ' �/�' 1 t/\ 1 .l a
g 0 0
Licensed!Professional
, W
�C .
W—Y.• OWNER-BUILDER DECLARATION
C?2 I hereby affirm Nal 1 an exempt from the Cocom cmra Litems Law for the
MW F M following coin.(Section 7031.5.Business and Professions Cade:Any city m county
no
which Rqu1Ra a permit to construct,alter,Improve.lkmn116h.or ropan an,eWCWf< ,S FI. Floor Arca
- Prior to its i.aumm,alga requires theappliam for such permit a file.siBneda-ument q•. Valnatlon
that he is licensed pursuanno Ne previsions niche Contractors Lianu Law(Clop orl) •'
(comuntncing with Skim]000)of Division 3 oldie Business,and Profession&Cade)or ' -
chat he is exempt therefrom and Ne bans for the.nailed ax<mptiaa.A.,violation of APN Number it Occupancy Type.
Stcmon]031.5 by any applicant fora pemdt subjecu Nc.pplicant to a civil p<nslty of
,p I more than rive hundred dollars($500).
I,aaawnerprNepynp<ny.ormyemploYeeawithw.ilea-Neir.meaamp<n:.non, Requirerl.litspections
will do the work,and thevaucturc is notimcndcd moRercd fonele($IA614,Businen
and Pon..ioru Cade:no Contactors Lianu low door not apply to an owner a
property who Wilda or improver thereon,and who does such wort himself or through
his own employees;pravidad and such impmvemenu ere not intended or offered for
sale.If.how."Ne building or improvement is sold within one year ofcompletion,the -
owne'lwilder will have da.W rden of proving that M did not Wild or improve for pur.
(] 1.s ole.). , a 'i
Las owner of the property,em s am contracting with Ilcene Commerce.
i.
can. Ne pa IIS I.]OH,BusinessIProfessions Co tied The Conlactnrs nd - -
cense urdocs mwt apply to an owmr of y who Wilds or improves thereon,and
w1Wmmrac"1.0 chpmjauwiNacon t gljcemmpmmmm Ne Contractors 7
Litems Law.
❑1'am under ,B k P C m rthi3 On
WORKER'S COMPENSATION UF.CI.AIUTTON v+
1 Aereby.Rrm unser penalty of perjury ma of Ne followia8 dlluations: - ��. IIIJ—'•, & .
I h.as and will for b in ectim 3700 of the L.Wr Code,
for Workers Compen - IV D
tion. r provided(sur na Ss i... 3]00 of the LaWt Gode.fur the peAnmunce n�the APR'1, 8 2000
k have whic
this maintain
ors, a
My have and will meinmin plackets CompensaJon lis for hi h us Forr by5ssued rY
of the I- o Code,for the Performance of d iwork for which this permit u issued. fill!!
MY Work ons do Insurance curies and Policy � � � � •
tune" Policy No.:All — p
IrTC OF EXEMPTION FROM ORKEBS' BY.—__�_______._��
COMPENSATION INSURANCE '
(This section need trotbecomplelm ifthe peris forme hundred dollen($100) x
or less.) mit-
I comfy mut in the performance of Ne work for which this permit is homed.T that
nes employ any parson in any manrter m min.becone'ubject to the Worsen'Compcn-
-tion Lows.f Calili mia.Dau s -
Applicant
' NOTICE TO APPLICANT':IL afar malting this Cenificate of Exemption,you should
'become t-Noct to cote Workers Compen-tion pmbisiuns of Ne Labor Code,you moa '
fo mwilh comply with such provisions or this Forrat shill be doomed rooked
CONSTRUCTION LENDING AGENCY
0 Homeb,vifum NUNlei.a Wouncelmn leading.eency,forth,pmfiaxxaue of
!a. Ne wank for which this permit is issued(Sec.3097,Civ,C.)
.E+ Lendch Name ,
C Tenders Address - - -
0.W Q 1"Ad"Nat I have mud this application and sme that IM.hove information i. -
Z .tact.T.forte to comply with adl eny and county ordinances and veru laws relating m y
building c..do..anal hereby aurhontc representatives or this city to enter upon tM - -
V O W'o-mommuml properly for lnawdom purpose.. _
(We)as,.m save,indemnify and kap lu m less Ne City of c,ortino against
.0.W lieem,eimear of the
and expenu&whi t wry eccmeegunn said City
'>a LT7, in<onuqucrue of the granting of unit. -
r 1 ERSTANDgA D\ II.1. 'DA LY WITII ALLNONPOINT
RCE REGI'
Signaare of ApplicantlConttactor Data
HAZARDOUS MATERIALS DISCLOSURE
Will dm.ppliccmmfmuie Wilding morpmtaauorhatilehaaudousnuunJ Re-roofs
aw defined by the Cupuano Municipal Cade,Chapter 9.12.and the Health and Safety '
Cade,Sealim A5532(q] Type of Roof
❑Yes
'WiIlNeapplicantorfmureWildinglcupemuseequipmemord=viceswhich All roofs shall be inspected prior toany roofing material being'
=mit hethedou.a it Wdmminmuo nod by Ne Bay Area Air Quality Management installed.If a roof is installed wifhoutfirst obtaining an inspection
I a reerto remove all new materials for inspection. Applicant
❑YI rvn gg
understands and i orq� I with all non point source re ulattons.
1 have read da haruNwa ma 'ass mens under Chapur 6.93 of`le Cali. ''I PVY g
Imnu Health&safety code. Ins 255 25333 and 2Ss3q.I understand tha
nodding door not came, ha coma t,N ria my respunsibnity,to notify the
rcymrc al to iau.nce ofaCenif Ie of Occup
'was .m a ad.ge a� Signature of Applicant Date
All roof coverings to be Class"B•'or better
a.
OFFICE