00030220 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR11"t[FORMATION: &00
BUILDINGADDkESS:
SANITARYNO. APPLICATION SUBMITTAL DAT
ON'VtgNAM�_:
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NC: ❑
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ARCHITIiCf/ENGINBER BULDING PERMIT INFO
n00
F i LICENSED cONTRACroR'S DECLARATION
'eco=o hWashy am=that lthnlicensed!under Provisions.rChapter 9(emmnenemg Job Description
Pm w
in fall
;orae wisho.]000)a;DivunonJofw Bminessand Pro/esiona Cade.and mYli<enss is
<yS� inns eRect. /v_ _ ��� mac, 1 _ —�
n n< IJceii Clew Lie.a .lajtY7 ,( f_` aL/.fr111�i T11v1 /K/ra`7,+1 Iv y`M-w6g sr'
nxl 5 LL y
Dit Contramar
a O g ARCHITECTS DECLARATION
I understand my Plans shall M used as public records
u.ROLicensed Professional
o. OWNER-BUILDER DECLARATION
F z t 1 hereby a1Brm that I am exempt from the Contractors License law for the
5 Z O following reason.(swoon 703 1.5.Business eM Professions Cade:Any city or county Mwhich"mine..permit m comwn,eller,improve,demolish,or repair any structure priormit,issuance.aleorequircawapplkentfmmchpri.face signedstatement Sq. Ft. Floor Area Valuation
that he is licensed pcommit low Provisions of the Conuanare Linea law(Oupta 9
Icommcn<iog with Section]000)of Diviai.n3of NC Bu[ineasand Profeuiom Cede)o APN Number Occas Type
dust he is exempt therefrom end the basis far the alleged exemption.Any violation of Occupancy YP
Section 7033 by any applicant for a permit subjects the h-Mile—m a civil Peraty of 3� V
4more Nen Eve humdrcd dollars 15500).
1.an.wner.;th.prop-ny.or my employees with wages as their sole compensation. Required Inspections
mei1 dofework,node: he Cmisisnot inmhded I-mr does
eM Hufwhom Cale:The oyes there License law soca av apply a if owner of
hpropertyis Man who Mild.o improves such i end who win.wino wmk himsslf of through
his own emptor,-e,Provided Net pooh improvements thin not inmMM in oRemd for
acro ever,w Wilding or im emnu iwithin one year oe on,w
Wrier-budder will have the budn ofFroving sat he dinet Wild in improve for pm-
Four f
u-
pourof.siWen.
1.u owns of the Property,em exclusively coovsctine with:)The
conacloes t.
tomac u d es esu ISa.70ga pias send Profeuiom Code:)The C therenra Lit /
ome law coca net appal w r of property wM buddy o improves Nueoa,dud
who conlMts fonuc in cis sit econuacmKsllicensed punoun mthe Contractors 7Y/
License law.
Diane Ue,5 .B&PC dun
Owner Dete
WORKF.R'SCOMPENSATION RATION
I herby alms under penalty of perjury one of Use following dech aeuoru:
400,1 have and will maintain a Ccnifcnear Continuo elf-imurt for WorlecesCompen-
sation,as provided for by Secuon 37M of the Labor Code,for the padomunce of the
work rot which this Permit is issued.
❑1 have sed will maintain Workers Compensation Insurance.as repaired by S.W.
3700of the tabor Code.for the performance ofw work for which this permit is issued.
My Wokcm's Compensation Innurence cnmer end Policy number are:
Caruec Policy No.:
CERTIFICATE OF EXE FIOONFROM WORKERS'
COMPENSATION INSURANCE
This secli.n nom Hol M c.mplettd if the permit is forondhoolred dollars(5100)
or las.:
I venify that in thepanfomuvice ofw wok for whichthis pnmit is uMm.l shall
not employ any person in any manner to as to become,subject,to the Warton Compen-
sation laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this CenlBcae of Exemption,you sbauld
become aubjW m the Weaker.Co i'mali.n provisions of the labor Code,You it
fo hwith comply with such provisions or this permit shall M domed invoked.
CONSTRUCTION LENDING AGENCY
Q Ihereby am.that them is n oonsbuction lending-91-Y forme performance of
Z Ne work for which this penin is issued(See 7097,Ci,C.)
Lenders Nthne
> linden's Addnu
W 1 certify that I have read this application and cum that the eMve inrormnd.is
0. eonat.I agmen to empty with ail city aid county odivnees and suer laws relining so
.D Z building cwsuuction,and hneby euwrie represenleives of this city m enter clean,the
C.1 0 ebuvcmemioncd pm fo 'nspectian puryoss.
W mer (W-) mnify and keep humless the City or Cupertino against
0 U limibues,jad u.em a eapanm which Huy in any wry accme sgrust mid City
W in conssqu - f w u n of Nis permit.
(•w Q. APPI 11 S' N DSANDWILLCOMPLYWII'IIALI.N0 -I'OINf
V Z k ' E�' NS.
Signamrcor Applican✓Convectur em
HAZARDOUS MATERIALS DISCLOSURE -
Wiillthe applicant orfuture Wilding meoprotstore orhandle hsendousMgt aial Re oo
as dcbncd by the Carman Municipal Cad-.Chapter 9.12.aid the Health and Sorely Type OI ROOT
Cmc,snti.nzssu(n7 �( YP
(:3 Y. ,.-
Will the applicant or future Wilding occuNpant use equipment m devices which All roofs shall be inspected prior to any roofing material being
mit lundous air conWnihants aadercd by the Bay Area Ab Quality Management installed. If a roof is installed'without Irst obtaining an inspection
aeR I agree to remove all new materials for inspection. Applicant
40 IF- ❑olyl-v
o
Ismalrsiala mluirtmenteunacr Chapter 6.95 of w Cai- understands and will comply with all non point source regulations.
f - r 25505.25873end 255 .I uMmued wt if w
itymnmify N occupans
of st nn prior ro isauenea of e C m of pahcy.
1 O d Signature of Applicant Date
Owner or authorised agentI Dam_
All roof coverings to be Class`B"or better
OFFICE