00020164 FBUILDINGADDR
CUPERTINO - PERKING,
G DIVISION PERMIT GOVT a 'O�R INFORMATIONI SANITARYNO. APPLICATIONSUBMITTALDATE
.f NIC CONTROLp
HON Lk2 7 O Z. ❑
AR41IfDCTR? GINF.ER / HULD'INQ;I;P.RMI'Ijl_F9
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t— LICENSED CONTRACTOR'S DECLARATION
oz., un�o IherbyaffrNalI It..nsedunderpoviaimoCha
anl)(cummeming
Job Description
f,=tw wishll to=7000)af Diviaion3 ofthe Business utl Profwiom Code.WmYlittntt is _ /. O� ^-
x rc z a in full force W.Rem. 1LL'
x ce ee O Liemr<Claia U,M
u 3 a DateCam,mmr
ARCHITIC1'S DECLARATION
I understand my plans chill h<uud u public mmNs
C
d1 y Licensed PmfeUlcard
to OWNER
N OWNER BUILDER DECLARATION
F Z>•MI hertby affirm that l em exemp furor Ne Comrotora License Law for the '
following reason.(Samar 703 L5,Business and Indications Code:Any city or county
wNN rapid.a permit in comwn,slur,improve.demolish,m npur any wicrure $ F'[.t�']O Ar(:a
poor its issuance.also regoims the applicant fonuch peamit m file.signed statement q• /� Valuation
Nat he is licaneed pmauanno the pursuit....f the Connectors License Law(Chapter 9
(commersum,wish Section 7000).(Division 3 of the Business and Profession.Cedc)m
Net he is exempt therefrom W Ne basis fin the elicited exemption.Any violation a APN Number Occupancy Type
Section 7031.3 by any applicant for a Funds subjects she applicant to a civil pnulry of �J O
wo mart Nn file hundred dollars($500). " 4
p 1,as owner ortheproperty,ne my employees with wages a.their sole compemwon, Require(] Inspections
endwill Pothewmk,endo:M mnianm invndedo Linsdoes We(see.1044,Busimve - -
ro arty who
Code1 The ov"th mr'c Licence Lew alma nm apply m lf owner gh �a
his o ny who build,or improves thcrtm,anld who alms such work himself or tied for {� I
his own lurpliymweve,eeq provided improvement tech impur..old w art nm ymw"r m oHemd for B U �.:..+
sale.,Wild v will haethe grenof frvin [..old did omyavof prove for
'owmrbuildm will have the burden of proving that ha did not build or impose for pury
putt orealeJ.
I,es awns of Ne popery,em nclutivdy convecting wIN licenttd contncmn m '""`t� ,1;�T�•Ja /��"'\
.menet the project apply
to an owner
of sed ny who bun Code:i Ls
came Law alms not apply to ts owner of papery who builds rs impuvee thereon,and (W ,1� ;1 I I it y \ J
whonadsfarsuch pmjectaNcontractors) w
del licensed pursm Nac
the C.nomre < JJJ Ya.l `„yr✓
License
Law
p Ion comp under Sec. - ,Bk PC for this reason t� 1�
Owner pate `t■j'
WORKER'SCOMPENSATION of.CLARATION
I haebYdl ossi under penalty to perjury We of the(.slowing declarations:
❑on,.and will for
eCion 37 to of the ard to bor Code.
a Wmkeh Comp en- /
work(r provided fpe so Seedon 3700.(the Labor Code,fm the perfomuucc of the
work Ins which this urnsiis inmd.. -
371have Land bor Code,
Compensationfthi,wrkfor ce,ra which
per by Second
1MyOof dx Labor Cads fm dm performance of die ooh for which this petit is issued Ot^
My Wohds Compmantion Inaunnce.enicr and Policy number tie:
Canner: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' -COMPENSATION INSURANCE
(Thi,uxtinnnead.tecomplcW if Nepernut is foromhunAcd"We(SI00)
or Ices.)
1 ccnifY than in the perforarce.ftbe wort for which this pamdt is must,l shall
not employ my From in any insurer an as to become subject to the Workers'Campn- '
.cation laws of Ca ifomie.Date
Applicant
NOTICE TO APPLICANT,if,aflat malting Ni,Cci ifinm of Erempim,yam should
become subject to she Workers Compensation provisions of the Labor Cade,yam must
f.nhwilb comply withtech provisions in this permit,lull W deemed revoked.
CONSTRUCTION LENDING AGENCY
Q 1 hertby aRlr Net them is a connncdon lending agency for the pRomwcc of
Ne work for which this Firms is issued(Sec.3091,Civ,C.)
Lender.Nem.
[(r Landers Addreu '
W Q 1 unify that I have read tltis application and stale that Ne above information is
�ees,,tmmw.1 agree to comply with all city aM county oNinsim s and sum laws relating I.
UZ building consvucdon,and henbyauth H,,reprcaentativesoohis city to can,upon the
0 "W'u-n wdoned popery for hupction p opases.
Ik P (We)agree to rave,indemnify and keep harlms the City of Cupertino against '
0 U liabilities,judgment,comaoil expanses whichmsy in my we,eccn.againn said City
�a W in consequence of the granting of this perp. -
ti
APPLICANT UNDIUSTANDS AND WI LL COMPLY WI of ALL NON.POINT
V z SOURCE REGULATIONS
Sigtumrc of A,,hcmtJComwdr Dov �J
` HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumm Wilding..cumr.umem handle hazardous mavdel Re-roofs
to dcOmd by the Cupertino Mu el Cads,Chapter 9.12,mild the Health null Safety
Code,Section 23531(a)' Type of Roof
p Yea o
Will the applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to an� roofing material being
mit hvNam.0
acomemimnn fin
by the Bay Arcality M
Area Air Quou"Feem installed. If a roof is Installed without Irst obtaining an inspection
Fives
isomer?isomer? I a ree,to remove all new materials for inspection. Applicant r
Ihave nod tie hanrdmv material,termircmenu under copier 6,95 a the Cali- unclerstands and will comply with all non point source regulations.
from Health It Safety Cade.Sciences 25503,25533 and 25.53,,.I understand Nat if Ne '
building does rmt cunendy have it escort,duo it is my responsibility to notify Ne occupant y
0fthertomenown wmrb�Jlmat�.facanmcam "Ge'upmy. .
�/ Signature of Applicant Date
Owner oreuthdnzed eget Data
All roof coverings to be Class"B"or better
OFFICE