0104005 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: %pG.- U 0_5_
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ItU1L5G AUURGSS S1'IiRMI'I'N(1.
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(rWNBR'S NAMIi: _ A PPLICAI ION SUB DAT E!
SANITARY NO, CONTROL NO.
TO
' G eea ARCIIITECTIENGINEER: BUILDING PERMIT INFO
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LICENSEDCONTRACTOR'SDECLARATION Job Description
Q _ hereby(niol and um IltnmeWunder land Proteof Chapter.I reavin,
m1-m wlh Scclinn 711dlq of tris nn3ef the Bu,incrn and Protevuonn code.and mylicunve
¢te is infthforseandelra'Lasi
C x¢ Limnw,Class Lm ea
O n O Dane Contractor
ARCHI'I ECT'S DECLARATION
L u ON 1 madertand my plans.,hall he toed u,,ohne mcords
to i C O LicemeJ Pmfeasional
ic
1)MINER-BUILDER DF:CLARAI'ION
iei3 I hereby aEma tinct I an x aa,pl four the Com...,,,',License Law fm the
Iullowin,rein.....(Section 7031.5,BuIdoev,unit Prof..on,Code Any clay lir county
F O which neWme,ape hit l r,marc, he,it dinaudikh.ar tend,any Inucmre
w 3
mi n t t elm I .me ai,diwamr such in 11..signed statemet
'but he ..I marsto II the p m Ill'IM1 Contract-',[ c 1' (Chapter 1) Sq. Ft. Floor Area Valuation
Icnumtcnei ng Is in Sectima Wxlo)of IN vinlnn 3 of the[hotness and Proov,ione Cotler
I,,mut he i,exemp therefrom and the basis for the alleged exemption.Any vioLun n -
of Section 703LS by any applicant lin a Permit subjects the applicant to a civil penally
irrnm mom Ihim five hundred dollar,($500). APN Number Occupancy Type
eref the pmperly.oro,emplayces wlllr wage,us their rule n,n,pemmion.
Aill do(lie work.and the structure is not intended or offered for sale(Sec.7144.
Bovines,and Professions Code:The Contractor's Licenx law doe, on appy m an Required Inspections
errrnf property Whir builds or improver themnn,and who doe,such work himxll
through hl,,own employeesprovided that such improver no s are not Informed or
oftcn:d for sule.It.however.the hhllding or hninnocment iv sold within enc year of
co...plenim.the ownerhuilder will hoe the burden of proving Ihat he did not bridal
Improsc for Pedrosa of salc.l.
❑I,u,owner of the properly.um c,cluvivcly cm,hacting with hmnneal,runnel's to
Lmumo me aurce,(Sec.9094.Bit..neu amt 11 fic..ione Code:)'I To Csmmelsr',
icense Law loss not appy to an owner of oolveny who builds or improve%themed,
and who comma,for such projeeu with a commensals)lieemed pursuant m the
CortPI IV ALED
mmoh License l.aw.
❑tan, ,m nit under '.. .I1&P C for thi,raunn
Owner �'^�'`�''''���'y� Date `
ORKI?HS COMPENSINrION DECLARNON MAY 3 0 2001
I hmeby union under panahy of perjury ane of the following dccluaadmr,:
I have and will maintain a Cenifeme of Consent In.elf-insare for Worker's BUILDING
Compensation. as provided for by Section 3708 of the Lahr Code. for the
perrirm.ancc el the work lia which thin actual is korol.
❑1 have and will maintain W'orker's CmnpcnwJon Insurance,a,required by Section
37010 of the Labor Cole,for the walomnance of the work for which this pemnil is
rued.My Worker',Compensation Insurance carer and Policy number am:
Currier: Policy No
CERTIFICATION OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fPhis acction need not h cmnplefod it to...it in for nuc hundred dollar ,
(S100)or less)
I ccnify that in the performance of he work for which this permit is issued,1
,hull not employ any person in Tiny manner no no, ,,weonm xobject hI the Wo kcrr'
Cmnrynnmiun Lawn of Callfomia.Dam
Applicant
NOTICE TO APPLICANT:If,alta making this Certificate of Exemption,you should
Income subject tome W..me,Cangx.mion provision,of the Labor Code.you nmM1l
Q O forthwith 11 1,11y wllh amh.....vMoos lir 111.1 permil shell be d«n:ed revoked.
z CONSTRUCTION LENDING AGENCY
a > I hereby anima that them is a construction lending agency for the perfomance
of me work for which alta I,a.Yl rit i,issued(See TOO.Ci,C.)
Q I,cndcr'n Nature
z Lender's Address
U C 1 ccnify tical 1 have mad this application and nate that the acwc information is ,
Va. F.1 rrect.I name Tia mnnp1y xuh al city nod coumy nNinunee,and,amu law,relating
0U m buddingmn onarion. mo
Tied hereby tmtharie rcjamsculrmv f(his My lounter upon
the acwcmcntfnned no,eny for inspection purlmses.
IWbl agree losave.iatemnily and keep harmless the City of C.perT against
Vi habitues.judgmenn,cols and expenses which may in any way acemc against,aid
U z Clay in enn,equeaco al the Staining lit thi,p:rinit. _
AP LICAN'I'UNOND WILL COMPLY WITH ALL NON-POINT Issued by: L r Dale
GULAG 3�C1—
sig lure of nppreunv'nmm"t,mI Date Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the uppher Por forme haddingocculwm shac or handle I..mNom mmenal Type of Roof
n,defined by the Cupertino hlonici,l C We.Chapter 9.12,and the Health and Safety
Code,Section 255321x17-
sues All roofs shall be inspected prior to any roofing material being installed.
will the applicant orfuture building occupentuse equipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
it hardous air contaminant,as defined by the Bay Area Aar Qmalily Slaoul,m umt
n,lrimaall new materials for inspection. Applicant understands unit will comply with
iON,, Irl, all non-point source regulations.
I base rad the 1m rmdous mmlerims rcyairemrnrs under Chaeta b.95 of the
@lifomia Halth&Safcry C,.Ic,Neatens 255115,25513 and L5531 1 under mad the
It the bndthng docs not,aunts M hove a rushes mal it i,my inept...of
ity m soli li the
oc vpum Til the reN'vancmn which anent lir nml prior lu isvuunre of a Ccnitieum of '
'Vile, ITe Signature of Applicant Date
All roof coverings to be Class •'B"or better
OFFICE