00040033 CITY OF CUPERTINO - PERMFr NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0(0O
BUILDING ADDRESS: 7
SANITARY NO. APPLICATION
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.s SUBMFITALDATE
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RCllOECT/ENGINEER `Yk0^ HOLDING PERMIT INFO
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O h= 1 hereby affirm NUE am licensed under psoviia ons of Chapter 9 Wouseming p
o z-o Job Description
Fir J with Sation]I%t(1)aDivisioulofine Busimsead Pmfassioas Cd<.ad mY littnw is
< in all Noceand:s 4�n �'-
w O 1 ClLic.x
$LLL DBIC COnVBetar '
_ O g CH.r S DECLARATION J
sy S 1 understand my plus.hill be used as public records �C�!/'�S
y oc
i D cc Licensed Pmfusionil
y n OWNER-BUILDER DECLARATION
1 hereby&Pore Nat 1 am exempt fest Ne Commutes License Law Na the '
A Z following reaaan.(Section]031.S,Seines,and Profcssiom Curie:Any city us county
ism which respites.permit mcommict,neer.improve.demolish.or repair any snanuc Sq. Ft. Floor Area Valuation
prior to it,iisuan«.also requires the appliaam fa each permit w fi «
Fit..sigd mem atateU on
Net he is licensed pursuant to than provisions of the Conecmrs License Law(Chapter 9 ,�
Icumnsncing with Section]MOA Division J of the Busineaa it profession.Cde)m APN Number Occas ane T e
Wt he is exempt therm cfmand the basis far she waged cannonade.,Any vmMultin of P Y YP
Section 70313 by any appbeem for a permit subjects dm applicants o a civil PWIV of
not more Nen five hundred dollen(SSOO).
❑I.as owner of Ne property.or my employees with wages 0 Nee aide compemsdw, Required Inspections
will do Ne work,and Ne structure is not lmnedd m offered Na.do(Sec.]We,Business
and Prolessmor Cods:The Convenor's License nae ladera apply to an owner of
property.1a,Wilde or imam..thucon,and w W dues such woh himself or Nnmglm
his own emplyees,pmvidd that such improeemens m era Maded a offered for
sale.If,however.she Wilding m impmvemcm is sold within erne yearof completion,the
owner-Wilder will have the burden of proving that he did not Wild or improve for Fa-
pose of We.). /
h as owuer of the pmKnY,am<alu.ivtly canvacdn8 with licensed conaanaa to
conswn the project(Sc.]Oen•Business ed Prefeesiors Cade:)The Cantractai Li- 1
come law coca.,apply to an owner of property w W Wilds or improves thereon,uM
who contracts for such projects with scomuctor(s)licensed purser to the Contractors D/
license Law.
❑1 am escmm udcr Sc. .B A P c for Nis season q�
V
Owner Date
WORKER'S COMPENSATION DECLARATION �s7
I hereby arm suer penalty of perjury oM of the(.slowing Wunsec iom:
Cl I Non, ha maintain
awill aCenificare ofConrsermuu
o lLwm
infor WoheYe Compn-
vtionf,arwhichdNd s fppeermi tSiecs istisouned
01 JT.
00 of Ne LeWr Cdc,for Ne pertomstec of tW
have and will maintain Wnhds Compensation Imurutec,as;required by Section
3]OOaf the labor`Cde orth pertortnance of Ne workit yfgor wQhic�h Nis permit is i.wd.
My Worth's Ks+mgcm by —cc coni poky No.'a��" ��Z
Coni¢ , ,\ �A C -
CERTfFICATH OF E) MPTION FROM WORKERS'
COMPENSATION INSURANCE
(This,dicer need not be completed ifthe vomit is(crone hundred dollen.($100)
or tan.)
I«nify Nat in 0nipafor l.fdre words forwhich t1u.,mdm is issued I Nap
not employ any person in any...w as to bcW.subjcuo the Warren Curti
Winn Laws at Ceifomia.Date
Applicant -
NOTICE TO APPLICANT:If,after making Nis Cie ifi as of Eeamptiou,yap mould
become subject to ds Workers Campenudn pmviumo of Ne Labor Cade,you moat
forthwith comply with such provisions or this permit mall be deemed revoke.
CONSTRUCTION LENDING AGENCY '
Q Ihercby aRrm tbu there is a comuucdon lending agency for Ne pertommm«of
Z Use weak for which this pmnit is issued(Sc.709],Civ.C.)
FLenders Name -
ai 7 Tenders Address
I certify Nu 1 have red Ni..pati«tion and state Nat Ne aWvc intermission is
1 ^� correct.l time,to comply with sR city and county ordinsntts uM.uta laws ecluing w
U Z Wilding constmnion,ad hereby emhmirn-Fouler-Weer if Nis city to enter upon the
U C .W,.-.rmimxx1 property for inspection purposes.
W I„i (We)agree to save.indemnify and kmp humicss the City of Cupenino against
lie lRW.Judgt«ms,cusm.nd pcnse6 whichmay In any way.ccmeagahm said City
y n comequ see of ger ring oIII,is pee t.
[� nAPPLICANT'I :R.TTAN S AN.WILT.COMPLY Won ALL N.N-POINT /
U S NRCE REGUI. 'IONS.
q oro n 7
r Sigmt HAZARDOUS
Dare y /4Ak 7 r%l CCs
FIAbkRDOUS MATERIALS DISCLOSURE
Willy the
o Collector r.Muni IP.1 Cgoccupentstoreo.MMle harudoais and Safy Re-roofs
asrefiocdio th<Cupertino Municipd Cee.Chapmr 9.12.sed the HcilthuM Safny Type Roof
eerie, 0yst xss3x(an a YP '
❑Yes
Will the.ppliCamm ce future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit Notations air conumNanu¢. fined by the Bay Arca An Quality Managamcm installed. If a roof is Installed without first obtaining an inspection
°l°°term] /
Ely. ❑No 1 agree to remove all new materials for inspection. Applicant
'
�Ihave read thehise=rd«n materials r,pireme.n prier Chapter 6.95 fda,Ch- understands and will comply with all non point source regulations.
\ Tomer Hee &S.tm Cee,Sections x3503,25533 and x 5M.I udmurM unit if the
Noma,
dues tune ly haveem LNat it is my¢sponsibility to notify the occupant
!the rtyuin,
whi mull t perm m las isme of e C[A�ry ficatj ofp«y saute.
Signature of Applicant Date
Owner ar aui seri neem Date
All roof coverings to be Class"B"or better ` I
OFFICE
1