00040119CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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CONTRACTOR INFORMATION:
PERMITNO.
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BUILDINGADDRESS:
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SANITARY NO.
APPLICATION SUBMITTAL DATE
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COYI'ROLx
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VH]'ECTMISGINEER
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BULDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I w licensed under provisions a Charmer 9 (commencing
- Job Description
with Section ]OW) of Division 3 of dm Bmime..and Prefeasiana Cade, andmy liana is
in full forte and! `0 G
LicenuC ss
_Lic.x
Date
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V
ARCHITECTS DEC !
T'SDECr
1 undemaM DIY Plw shall h esti as public records
Licensed Pmfc"iow
OWNER-BUILDER ION
I hereby affirm onn 1 rn exempt from me Conferences License Law for the
J Lp_,(�Nrg9
following as (Section 703 L5. Business Cade: My city st county
Sq. Ft Floor Area
alua[ion
mp wc.Prodennm
wart sequGp a pant, m coruwm, alar. improve, demellah, or repair any mentum
uum
prim toit, Neapplicant for
miceuignedChamem
caresedpatm u,tha me Contractors
Comm�ss LicenuLaw fC
thmmuse
Q"!�V
6.,widpursuns,ouse of MAmo 3de
ode) r
(co with Section ]0)07 iwu Cade) m
Dslas B3or the Busircump"..
APN umber
c ane T e
he is exempt
Iter he is exempt therefrom and Ne .Four for the j alleged emmant to Any violation of
the A
Section byanyapplicantfor apmNit objects de applicant,oecivil pccalry of
3 ��
y yp
than hmdmd (SSW).
rot momwne M
Required Inspections
x ty mm
wi Lothee of the pfopcny, ar my cmplgaa wile wagers deb cote compemadess
will work, and the is nm intcMed m fm
apply loan. Boniness
Profe Law do of
The Contractofs Liana Isco docs scot apply to lf other gh
hen C.m
and Prty
O'lao h ids.
property who builds or improvesand who docs such work himself m through
u suchn,
his own emp]oyms, provided Nsuch lmprarcmene art intended a oBc,m for
We. t. building m impmvcment is sold within one omplml
On
-
will h.
r-Wildcr old Or per pon.
e.). will Mrc tits burden of proving Net he did not Wild m improve fm pm
proa a
pose Wane.).
.. L u mvner of am esclus .0 nonessmui Coln licensed m
property,.,
-
unmmon
el 7041 Code:) The Conuecm
pmjm (Sec. ]rano Busiwnero Py
f property
come taw dans not appy to m owner of praftm( who,wilds ra improves thermal, and
Oman La sh Wits, i 1, nd
for such pmjaawith acontfutorfs)liunud pursuantmthe Cansrac,ofs
Lwho icamm w.
uanm Law.
G lane exempt under sec. ,B&PCfor this no
Owner Dan
WORKER'S COMPENSATION DECT.AIUTION
1 hereby e l u,:: penalty of perjury one of the following declmatioru:
j Iheve aM will matoaineCmificaseof Comenttoulf.insumfm Wo ezCompcn-
tion, as provided fm by Smuon 37W or the Labor Cade, for the performance of the
work eh this permit is issued.
/
have and will maintain Worker's Compensation Innocence, as squired by Section
O
37Mof the labor Code, for the ppewr�fo�r�m�aangcie of the work forwhichthis
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^pe7mot�is[iaeed.
('ga)pe ianl�tl/b� kcl
Cunemkers •
Pol< NIo.Y";i Y
�w� C}_ 141 IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section Wed! not W complemaddthe permit is forme hundred dollars (SIM)
or Seat.)
I cenify that in Ne performance of Ne work for which this permit is issued, l shall
rot employ any person in my manner so as to become subject On the Wafters' Compen-
mims "we of Ca]ifomia. Dau
APWicmt
NOTICE TO APPLICAM': IL after making this Certificate, of Exempuon, you should
become subject ,o the Worknla Compensation provisions of the labor Cade. you man
forthwith comply with such provisions of this permit shall W deemed revoke.
CONSTRUCTION LENDING AGENCY
1 hemby alien than Nem is a construction lending agency for Re performance of
de, work for which this permit is issued (Sec. 3097, Civ, C.)
Landers Name
IendrOAddecla
1 cmify that I bavc reed,hie application and stmC dell the above information Is
co.,. I agree m comply with all coy and ..my orditu mer and some laws ahting,o
building comarmu n, and hence, authoffu mpruena l,mli mMa city a mer upon de
.W. a-.cmkmcd progeny four inspection purposes.
(We,) agree to ave, indemnify and keep hefmleas the City of Cupertino against
habilinea,judgmene, cols and expanses which may in my way accme against said City
inconsequence or the gu brig .(Run; perm],.
APPLICAN IUNDERSTANDS ANI)W 11.1, CI)MI'I.Y W I'I'H AI.1. N(,N-IY)IN'I'
SOU EGDIN O
-dwua
$ Zee
tgnanum of AIicanV son r I Dore
HA7ARb01TS MATERIALS DISCLOSURE
Re-roofs
Will de applicant or future Wilding occupant orae or handle haturdour material
u defies by the Cupertino Municipal ode. Chapaf 9.12, and the Hearr amt Safely
Code. S.'iWM532(.n
Type of Roof
GYes
Will the applicm,offuture Wilding Occupant use equipmeot or dvviccs which
All roofs shall be inspected prior to any roofing material being
t"WhIu. ab contwinasua as dcflned by ,be Boy Arc. Air Quaity Management
installed. If a roof is installed without first obtaining an inspection
"°
❑Yat
I agree to remove all new materials for inspection. Applicant
d
un erstands and wit comply with II non point source regulations.
Iluvc rad the Infant mammals leyuirtmrnts under Chapter 6.93 of the Ce-
ford. Deem k Safely Codc, Sections 255()5, 75533 and 2553x. I uMerm nd the if the
building does and ewmly have a tenant. Out i, is my mspuuibiliy to notify the occupant
lg+i4 Nch mr`u prim, ram of. aap�xuppcy.
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gnature of Appl' n[ Dale
OvolO
Dw sed agent Dae,
11 roof coverings to be Class "B" or better
OFFICE