00030104 CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION PERMIT MORE II 1 RiMATIOk NI• 3O J 0 4
)) y� .,�:g. n 00
BUB.DINGADDRIS'S ala
er NL,/}/er/: 0//ly, l��
WIU/��I(i [�(/•JI/ yJ✓(��ryTL SANITARY NO APPLICq]IONSU �AOLDATEI
(304 N ML: 3 970 Z-, �g•��I// sJ/ #�D NIC IV2/CONTR(oOLk
SII ' A1RCH1�/ENGINEER �/ut� ���/�" ���Y5 Y ❑ BULDIN 171.RM1fI'IjI RFO
o o X572
LICENSED CONTRACTOR'S DECLARATION
1 hereby sffim,that l am licensed under provisions of Chapter 9(concentrating Job Description
Q_C vy with SceW3Z j1,,1Dnvii 3 f Busikss C my"mon".
CyE7 in NII(onceaoeffect, j�////1%1P //IP/J T[DH
a< Liana d� Cost VV N/ r //` /Li/ teeolkm fi f
Dem Lic,
ARCHnTi-CTS DECLARAU
pg`{ ot-- 1 understand my plans mall heated!ao public membi
tier O UOusd Pm(euiolW -
"Kf
OWNER-111111-DER DECLARATION
1 bcrtby affirm that 1 am exempt from Ne cmumsect.e.Ucenae Law for to
F p "bri ing reason.(Section 7031.5.Business and Pmfeviom Cade:My city or wanly
C which iso a it to construct,alter,improve.demolida,or en mousure
a.3 m "S" per"' p easig y Sq. Ft. Floor Area �V��tio�O
photo its ixmance,also rtquirtsthe applicant forauch permit in file uigrld alum"Rad / C/
Ron he is licensed pursuant to Ne provim.at.f Ne Contractors License taw(Chapter 9
(cumrencingwith Section 7")of Division3 of the Business and Proferlons Code)o A N Nu bar Occupancy•ryI e
Nn he is exempt therefrom end the basis for the alleged exemption.Any violation of �t� �O p y .,f p
Section 7031.5 by any.p,h t for a pe.I,ubj.ts the applicantto.civil pe Wry of 4✓s
not mon than fee husdrM dollars(SSBI).
L,ar what ofthe pre my,or my employees with wages a re'v sale compensation. Required Inspections .-
will do the work.and themin"e ,In.1mounted ca.Med for We(See7044,Buaietesa
and Pmfeadons Code;The Contractors Liamse law vias no apply to ser owner a
property who builds or improve Merton,and who does such work himself at through
his own employee,provided that such improvemenu are not intended or offered for -
saleIf,howaver,the building or improvcment is sold within one year of completion,the -
owno-builder will have the burden cef proving that he did not Wild or improve for par-
- poseof salol
I,m owns of Ne property,en exclusively conmating with Ilceneed contractors m
construct the pmjat(Sec..Re B.of tad y.1mWiCode:)Thes.ftro..Li-
came law dna nut apply e ts owe of property who Wilds rs improve thereon,and
who wnuacu(or such projau with acontractar(al licensed pursuant o the ConmdNa -
License taw. /
❑.I em exemptunder Sa.. ,B&PC for this rtasan
Owner - - net. 3/
WORKER'S COMPENSATION DECLARATION
• 1 looney affirm under penalty of pce erjury aof the following declensions: n
El I lieve end will maintains Certificateof Consent to self-imurt foworkeYa Compeer-
cation,as provided for by Section 3700 of the Iabor Code,for the performance of the
or which NO permit is issued.
Q4O and will maintain Workers Compensation Insurance,in required by Section
3700afthe Labor Code,for the performance ofthe wok for which this pent is issued. .
d Policy
M Woeke�s�pgy�pf�ti �¢ytyq cc,.ypn an
Cam'er: ✓/�'1�P_�f—UNC_1 Policy No. num �D�/D�
CERTIFICATE OF E.KEMPTLON FROM WORKERS'
COMPENSATION INSURANCE
(This section nod not be completed if the pemdl is fm orc Wadmd Loins($100)
Re leo.)
1 certify that in the pertormroe of the wok for whichihis porous is issued,I shall
not employ any person in any manor so as to become subject in the WarkeraCompen-
moion laws of California.Data
Applicant
NOTICE TO APPUCAN7`,If,afar making this Certificate of Exemption,you should
become,object to Ne Wmkrrs Compensation provisions of the Labor Code,you must ,
forthwith comply with such provisions or this permit hall W dement revokW.,
CONSTRUCTION LENDING AGENCY
Q I hereby affirm visa there isaconswction lending agency for de perfo.a of
Z the work for which this permit is issued(Sec.3097,Civ,C.)
F,a Lender:Name
Lenders Add., ,
W 1 cavity,Nat 1 have rod this application and xtate Nat the move information is
n. mnect.I agree to comply with all city and county ordinances and arm laws misting in - -
.7'Z building conometion,and hammy antWnareptchmtsives of tut city to enter upon the
U Qabove-mentioned property fns inspection puryasea. '
Lr, E. (We)agree to save,indcmndy end kap harmless Ne City of Cupmm.agsbst -
Q U liabilities,judgments.cots and"porous,which may in my way sane against old City
�. W in conreq imoo,of the gnndng of this permit.
► 'APPLICANT UNDF RS'rANDS AND WILT,COMPLY WITI I ALL.NON-POI
V 7
SOURCE
F7 Signmm,ofApp aoVItAZAData
RD US MATERIALS DISCLOSURB
WiRNe. so Wilding aa,sni store o handle haci motend Re-roofs '
in dcfned by she Cupertino Mu to al Code,Chappa 9.1;and the Health and Safety -
CW.,Satianu53A.)7 Y Type of Roof
❑Yes
Will the applicant or furt Wilding mcupant use equipmaoor devices which All roofs shall-be inspected prior to any roofing material being
emit hawdom it cuntaminenm as defined by the Be,Are AU Quality Mmagemenl installed. If a roof is installed without first obtaining an inspection
• °"""" t� I agree to remove all new materials for inspection: Applicant
❑Yes d
,"on,eddehanrdn".mhmnd"hami'iRace'Chapter 6,95ofmaCahi- un erstands and will comply with all non point source r gulations.
Wilde Hu1N R Scurry Cade,Sansom chat i is my eM u53a.1 u rosily s that if the - U -
formsHeade,natcuerently ty Codavemmoanitho it is my rtnd255 ibty tonrmundhat if ard
f
of Nen menu wh' theta,Our to lnsusnC.mfe CmrB le ofp� ync
C �/;�/ 9 Signature i nt Date
Owne...........
"gem fir— te
All roof coverings to be Class"B"or better
OFFICE "