00020089 CITY OF CUPERTINO PERMITNO.
BUILDING
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51PERMIT CONTRACTOR
N�T�R^Ar�C3(oO�0R� INFORMATION:h�w�tus 006 O d 7S�t
BUILDING A)M4FSS1 SANITARY NO. APPLICAT
IO�SU
B
MMALDA
D22f575AN JUAN �oa7
OWNERMEVv � / �OQ
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HITECTAU4GINEER a r� BULDINGPERMIT INFO
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'O m= LICENSED CONTRACTOR'S DECLARATION Job Description
�y_� I hereby aRmr Net 1 em under uer provisions of Chapter tmne
9(coneing p
FyI_w wiNsation 7000).(Division3oftW Busineeeurd Rofessi.na Cade.and mylicenu is
I.Nil gtSla2 { PjY INSf'At-I IN
e O a li«rue Class
aiDyu DAtc c2��Conac hTARL �f67fL �IGLv�E CXtsrll`•� �O(r-�I "1 ,
w OARC HITECTS DECLARATION
C y I undenurN my plans uWl be used as public records mew W t N co sv. v K 6'r• to
1 W A't-�- P6h1[N(�
° Iiren,ed 1'mreasiotW JZ LC�rM•P if-0 N O L r t e tY t3 D L.tA6 L til 4 1'OoM
OWNER.BUILDPRDEMRATION -('�.QE -rErX {P"'IAr' Livw(o Lacer. ItJYtkLA- (=1IIISH FtooR-
i->a I hereby aRmt that 1 am exempt from me Contracmes License Law for the I n)esti
`F C folMnng tessoN profession.(Section 7031.3.Business aprofession.Coh:Any city w county
Ce
3 m which requms,a permit a consww,Wee improve.demolish,or repair any.trunnre Sq. FL ploo�Area Valuation a�
prim to its issuance.also""res the applicant for such permit m rile•signed statement 1 /
that he is licensed pursuant to the provisions of use Conealor's Beare Law(CMpur9 !/
(commeteing with Section 7")of Division 3 of NC Dust.,and Profession,Code)Or APN Number ecu ane T e
Wt he is Cumin tm aM erm mthe basis for men Alleged exemption.Any violation lir q G P Y YP
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty Of 3+/�
t more Nen rive hundred dollar($3001.
-
p I,as ownerarmepmpcny,armyemplay«a witw.g«uNemromnompewtian. Required Inspections
wail do Nesicins Me:TheCeisata ire«Med Law
apply In 6,Buainea
end ProfeaW Cade:The C e,bere'a."w law docs not apply m lf mune.d
proptny coed build,or improvCh Nerthn,nM who dms such work e deed or or Nmugh
his own employ h provided Nor such imp.is mid ss art most intended r.Rood for
sola If,however,the building or i n of proving
ado,h within one ye Or improve
ted j
.-build«will have Nc buNen of poving mal he did ata build w imgovr.fm you.
Pose of telesis
1,as owner of e, property,un exclusively Probating with licensed contractors i- /
O n. La NC or not (secs oaa,wner of AM Rowho Wild,
Code:)The Contractors Li-
On.
d
whoLaw due.coat applytoan owner o/proper(was Wild Or impravex torero,and O
who covens for wch ptojaa with a conwctor(s)licensed purswnl to Ne contractors O
Cleaner Lew.
❑lash exempt under S«. .B&PCfor Nis tcasan
Us
(hvwr wORKF.R'SCOMPENSATIONDECIARATION LMARO
under penalty of perjury one of me following declamamrx:WqIW tion,as MO,,d,d tar by section 37M of the Labor Code,for the performance of Ne 00k fm which NI.permit is issuedtd I have and will nu imuim Worker.compenwion insurance.u reqired by section3700.(to Labor Cade,for me perfmmvee ofNc work for which Nis permit is issued.
Mye,�peruro��y«edPolicy K " -
Cerier:
CERTIFICATEOF]EXEMPTION FROM WORKERS'
COMPENSATION
INSURANCE
TNR section used nor be Completed if Ne pcmut is foroahuMred dollars(SIM)
or less.)
1 cmify that in the performation of NC work for which this permit is issued,I.hall
ata employ any pecan in any manner w as to become subject to the Workers'Compere
union Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this ecni&ate of Exemption.You should
become subject to the Workda Compcmation provisions a me Labor Code.you must
fonhwm,comply wit such provisions or this permit shell be dnemed invoked.
CONSTRUCTION LENDING AGENCY
Q O Ilumby.M.lhis Nem is a Concoction lending agency for the performan«of
L @e wink for which Ni,permit
is issued(secs 3097.Civ,C.)
H Lender,Name
> lender'sAddress
W I Certify Nat 1 have reed Nis application and auto Net the above information is
0. Qor.,.I agree to comply with all city and county mdmil and num hors OCNO-9 m
7 z building construction.vol hereby aummui,rtgesenelive,ofthis city to enter upon the
U adwcmemiwed property for inspection pury.s«.
(we)agree to save.indemnify end keep hummer the City of Cupertino against
U lilbiliti«,judgments.emu and expau.which may in any way accee,urnat said City
'y W in commqucwc of the gran ding of Ods permit
(� In APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON MINT
U DO SOURCE REGULATIONS.
igvure orApplicanVContrecrar Due
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant or future Wilding accuWnt lose or handle haesidous maarial Re-roofs
in defined by the Cupertino Municipal C Chn'us 9.11,aM Ne HUIN acrd Safely Type of Roof
III Code,Sectiwas3aan YP
❑Yes
Will IN,applicant or future Wilding aaupam use e9uipmem or devices which All roofs shall be inspected prior to any roofing material being
mit harardous err Containment
as deE by the Bay Ara An Quality Management installed. If a roof is Installed without first obtaining an inspection
mI a ree to remove all new materials for inspection. Applicant
❑Y«
Ihave rtad Nc build.. maleriah rt,aiem«ra arrderCnaPwb95.fNe esti- un erstands and will comply with all non point source regulations.
bulla rig
&lSafetyCe Cada radon,35505.25533 and 25534.I undersand Nat it the /�'a- ' e-z r 4-- !J ..f T
building do sats cutrtml emwnk Not it is my rtapumibiliry mnetifYth acupat / L L�/�'t/
of0i menaw btutupnwmiaauarceof.gCnif_caepf Occupay.
Signature of Applic"iZI.J Date
au hmize .get �f Daa
All roof Coverings to be Class•B'•or better
OFFICE