00080214 CITY OF CUPERTINO PERMITNO.
BIJILDING DIVISION PERMIT CONTRACTOR INFORMATION:
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OW'FR'S NAME: / \'�,/✓V t�l` yl//t r" r
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AR ErrECT/FNGINEIiR BULDINO PERMIT INFO
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H •^ LICENSED CONTRACT'OR'S DECLARATION
z o y? I hereby affirm Net 1 em licensed under previsions Of Chapter 9(commencing Job Description
O?� jul O with Sa,ion7000)ofDivision3of NCBusincssmdNfmiom Cade.asdmYliccmeis
y � in full force and eRect.
O U IJ<,na s e Lir.N
3 Dem Conmcm
S DECLARATION
O o I understand my plans tell�be mast as Public im,sds CA fie✓' -e 9A
I�<enad ProftuiorW
n uN1 R 15 OWNER-BUILDER DECLARATION
1 hereby affirm,has 1 un eempt from,he Contractor,License Law for the
t❑ following reason.(Seniors]031.5,Bmimss W Pmfnzimu Curie:AnY city m county
b w which mquirts a Pamir m comwn,alw,impmvc,demoliN,or rtpe'v any swnurc Sq. FL Floor Area SVaion
prior tiitsizsuaae,also rtquims tilt applicant fa such Pe,nmt m BIC\aigad sutemcm J
shut he is lie sed punuam mNepmvuimns of Ne Conv\uare License law(CNga9
(mmmcncingw)NSasicn7 W)ofDivision3oftheBusimMard reniomCnde)ea APN Number Occupancy
Nat he i.exempt,haefrom arm ane the two.for the alleged exemption.Any violation of P Y Type
Section 7031.5 by any Apparent fm a permh Subjects dse applicant to a civil penalty of
a m. Nn fie hndedollars(5500.p
Required Inspections
will aothework,andthe anucmna itemiLicens Lan dim apply
an owns
and Professions Cade:The COnuacmr a License Lew docs not aPNY m an owner of
his own who build.of impmvw to each
i and who does such wote n ed or or avough
his own employeese Provided Net such improvements art not Intended n oRered for
We.If,howese will
building an impfament is dust
h within one ywr improve
far the
of
Wee will have dna burcn of proving that he die eat Wild a improve fa parr.
Wed.
I,m owner id Ne property,,B exclusively contracting with licensed connamss t-
,ww La the,project apply
]OAA,Busmen and Py who ai Coe.:) no es thecmrs and
cervi Law does r s apply m ta owner of inamor tubo builds m improve Co a ratan.Sue
who contracts for such pmjaa with•tonnater(,)IircnrW pumm.l m cite Connectors .Q
Licenrc law.
Ina exempt under Sm. .BkPCfor this mown
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby,eKrm unde,r penalty of paPUY one Of the following dec'larasiau: _
1 have and will maintain a Certificate,of Consent to self-lnsum far WOTI ersCOmpen-
sa,ion,as provided far by Sar mn 37W of on,Labor Code,for the p,donnence of the
work iprsvhich this penitis is issued.
grlta W will maintain Wnrkcrs Compensation Bnuraece,n"noted by Section
3700of the Lab,Code,for the perfonwice of tic weak for which this permit u issued.
My Worker oaf��JJLLin Ounce carrier and Policy nu�rarrt:��.�7/
Cemien °./"- a"S Policy bhi:fA/7��
CERTIPICATE OF EXEMPTION FROM WORKERS' t
COMPENSATION INSURANCE
(This section need not be completed dithe permit is rororchurded dollars,($100)
or len.)
I certify that in the perfomunce of the work for which this permit is issued.I.hdl
not employ my person in any manner an as to become mbjecmo the Wim,ma COm om-
suion Laws of Califomi\.Data
Applicant
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should
became,a bjaa to do,Wooster,Compensation provisions of the Luber Code,You muss
forthwith comply with such provisions or this permit mall be domed mvaed
CONSTRUC ION LENDING AGENCY
QIheeby Orion that drcrt is a costmcuon lending agency for the perforwtce of
Z the work for which this permit is issued(Sec.3097,Civ.C.)
F„ Lender,Name
(,Y } Landtea Addrez,
Fz I tarty Out I have reed Jun application W ionic Out Ne above infonutimn is
L carrot.T avec m tomPly with all city end county endurances and mac laws nationals an
D Z building conssrucuon,and bceby amhorio opreenwives of this city to enter upon the
U adsve.mentionnd Property for inspection purposes.
(We)ago,m.eve,indemnify and kap harmless the City of Cupertino against
V li,biliue,judgments.costa and expense,which may,in any wry nerve against said City
} fs7 in consequcoc of the venting of this permit.
[•• 6. APPLICANT UNDER NDS AND WILL COMPLY WITH ALL NON-POINT
� All) S.
uZ
Signorina of Appliceoncommucror I Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding rampant store or nardlC harmemm material Re-roofs
in defined by the Copeman MunicipalChuTom 9.12,sad the Health and Safety Type Of ROOT
Code,Sentinn 2 532(alt [ e. YP
❑Yes
Wel the applicant or future Wilding occupant use equipment ea devices which All roofs shall be inspected prior to any roofing material being,
mi,In oodous air conamhunu o.ayatw by le a Bay Ar ca Air Quality Management installed. If a roof is installed without first obtaining an inspection
AniI,nin, �/ I a ree to remove all new materials for inspection. Applicant
❑Y
Ihave ted the har.rdom m\adal.tecuimments undo Ch.,.6.95 ofti Cali- un erstands and will comply with all non pont source regulations.
fomite HCAI ray code.Sections 25505,25533 and 25534.1 a and that if the
buil upand U�
Ne a hpuiat t pnea ro inuaae of a Cyte' y�o�
it r( if3 Sign Pure of Applicant Date
Uwtter m pram
( All roof coverings to be Class"B"or better
OFFICE