00030200 ' CITY OFCUPERTINO PeRM1TNo.
BUILDmro ornsioN PERMIT',,, . CONTRACTOR IIVTOV' 4A'TIOI\l: ) t
BUILDINGADDRESS: . • - t
&�/� e t ��� n� ` `v/.eg �R C, SANITARY NO. APPLICATION SUBMfITAL DATE
OWNBR'S7AV/M�/�E�V�+ �f '1 J� A _ d -�.�.7 O(S'•'
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PHONE: l�Jff l/!O' S,JEPQ �+ of ❑ - �O GI
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nRCHITEC'ENGINFh '' ti r• U D PER Ifl F .
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i LICENSED CONTRACTORS DECLARATION - 4 � � ' p � •tr
b 1 hereby affirm that 1 em licensed undo provisions of Chapter 9(conmienuog C�'-' ` Job Desenption'
F l= pwtN Section 7000)ofD 'i 3 of the Business and Profession Cade rtM ylitt
4 n ',a fill force mdeRect -
p, ul Litt CI s - Lc# h;
x o LL U Dere Convector m I'/'�
H i30v, undemmnd" ARCHTICT'SDEswelax�C bLARAlic r TION t. ���D�/VCM �'. l��N//Va'se//i(/[.F /".". L./Y_ a"✓i. at .. '
o.y Ao Prof _mud' i,
OWN .BUR.DEROECL' RATION /
I her by eR'rm that em exempt f theContractors License Law forth
'foil - g (Seco - 31 5 Bourton and Profeumns Code Any city m county * +
m^m winch q pe r l0 tiaa Ikr,improve,deiroliah - rtpu arty simcture 1
a a_ Sq.Ft.Floor Area Valuati
price to its issuance,also req rte the appy lforsuch parous mfl esignedaummet s,
I
that he Ice dpursuant t theP of the Connmtor L Le (Chaps
(Oma g 'the ti7").fD ision3oftheBusinessandProf 6 .Cod) APN Number
c u ane e
'Nath 's axe pt these( amid the taxis f the alleged exemption-Any viclavon Of AI p Y Typ
San than
5 five
e y applmxt fm a perndt ubjau the eppl antro e c vil peneltY,(
l mom Nan five hwdied dollen(8500)
11 las owma.1'the property.m my employ nth wages cath' I omperear n r '':Required Inspections -`
will do the ands: o clumCont is tors umbadl Licame Law ied dos not (Sec 7014;com rete '- - ' ,• •�
end emy who
Cede The Contractors.and Law does not apply to if owner of s
property who tau Ids or impmvn,such i pr who des mch wotk himself or through,
his own employ¢,,provided Chet such improvements em not intended or offered for d
mlelf,hower will havo the g ride overvim run
he id but Wild.,
rompletlon,the 'y
owveobuilder'willhreve the buNen of provin8 Net he did not build or improve for pur- ,`•y' i .M +„
poseof reale f '"
❑'1,x Owner of Ne property exclusively connecting with licensed contractorst '
nstmcl the proton(Sec 7044 B ancx aiM Prof n{Code)The C u cion L , ',r i .d e
cense Law does not apply to r owner of p k, h bac Ids a improves thereon and - // s 1
who c tract for such pmlects wish a convector(s)Icensed pursuantrothConvector - a'
License Law. +. •( s
❑lam a pt noun,S - B&PCfor Nn reason
• owns � � ' - Dare
- .
WORKER'S COMPENSATION DECLARATION - ' „I 5
I hereby a imn under penahy of Wrjury mm of Ne follow ng dmlamtimw: - R
❑Iheva and will maintain aCertificare of Consent to self-inmm for Workers Compsn- -
smon,es provitled for bySection 3700 of the Labor Cads,for Ne peFfomuamce M Ne u - "' „
work for which Nis permit is issued.
❑I have eM wil mai exam Workers CO ilmarnim insurance.'aI requited by Section
37000f rhe Le Code,for the ante of the wart for which this peemit is irsucd.'
oil Om mfn :
Ility NO:
CE FICATuvu, --.dP.fi,.mrxWr.:0N FROM WORKERS'A.CONSURANCEsectionneednm Permit i6 forone hundrW dollars(5100) 1 . • '
Ir AifythatintM1pelf mreof ihewmkforwhichtM1pe ii s.e ,lhe11 '
not employ say porton in any manner so as to become subject m the Worker'ComPen •°' r .Y "
sati Laws of California.Dere _ #
Applicant
NOTICE TO APPLICANT:IL after nursing this Cenificete of Exemption,you should
become subject to the Workers Compensation provtiam,of Ne Latin,Code,you must
farttiwith comply with such provisions Or this permit shell be dcemed revoked,s ss
z ,_ CONSTRUCTION LENDING AGENCY ` ' i.
Q I hereby efRrmthatthere's nsti edonkndmgagencyf tb peAomunce f
.the work for which Nis pe n is issued(Sec 3097,Civ.C) _ 1
Lenders Name n r ,
aa•,7 Lenders Addrtsa ., r
Lg7 A I certify that I h read this ap,hmi on and state that the bo information is d
0. 'correct 1 agree to comply with all city and county ordinances and toe'lawwsrelating to -
U Q building trvetiun and hereby thonmrt / ,- -
groin y u prcsenutives ofthnc ty, nser upon she
above (We)iredpropertyf erly anprWu.
(We)agree to c i d expenses
and kxP hayiiins theyCity
ace Cupertino against '
'>s V incoN queen ofn mu de penme which may in any way eceroeagmnst acid City '
µ }•0. inconsequence of rhe grantingof Nrs WILL
-F 'APPLICANT,U PRST2ND5 AND WILL COMPLY WI'THAI.L NON-PoINT
VIi
t..7 .SOU LATIONS.
0 1i. r np
w o ApplicanVC0 nor Date - -
RDOUS MATERIALS DISCLOSURE '
Will the applicant if t b ilding up ren mor handle hazardous mate i Re-roofs
f x defined by the Cupent u cipal Coda,Chapter 9.12,card Ne Health and Safety, ;
Code Station V553200? n' Type of Roof
,Dues 4+p t
# All roofs shall be inspected prior to any rooting`material being
Will the applicant or futurt budding oec p t se equ pm t do ih6 whmh s.
emit hewdoua mrconum nano as def yNe Bay Am. Qualry Management. installed. If a roof is Installed without first obtaining an inspection
District? � I agree to remove all new'materials forinspection. Applicant '
e .un erst ds and'will coni 11 with all•non point source regulations:
I have read Ne Weardws a enm'als teymmments rinds,Chapter 6.95 of the Csh-
forms Hexlth& S Safety Code, xions 25505,35533 and 73536.1 understand shat if rhe -
bund gdan
- otcamemlyhte
aveanam Nmnis mY ruponaib,liry mnmifY the occupant 1
afth 9 t whi h sn be met Pnmt ire ofaCMificare of Occupancy - -
Ig
re-MA nt Date
OwnerorauNonudagent .
• t - All roof C Brings to bebass"W'or better
r OFFICE,
r
t 1