00020049 CITY.OF CUPERTINO '' 1 PERMrr rvo
-, BUILDING DIVISION PERMIT CONXRIA RoppZ
BUILDING ADDRESS: �1t /yI d A /� /t� /�/�
7I Oe e (� VV4TE�//]R'//� HOi•TMEAQ i a• '•��111 , SANITARY NO. APPLICATION SUBMITTAL DATE
OW It'S NAM ' z• / /O �• /•/u/f/ !/JV
[[JJ NIC CONTROL#
Cra.� VaAeyd L'A 969ys
ARCHITECT/ENGINEER / �/OD.. ✓t i�!'���f Bu1.Dl'nIPCryMIT MPO
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hi LICENSED CONTRACTOR'S DECLARATION
��C I hereby.Rens that f am licensed undo pmvisions of chapter 9lco m;ng Job Description
F_Cj withgation 1p00)ofDivision3 of the Buaircaaand Pmfeviom Cde,vW icenm'
in full force ed<Rat _ GUater N2gl�r Rep/ll��%�2es�f
in full(Class Lm.#
01 3 u Dec Contrmmr
C s3 O eLi ARCHITECTS DECLARATION
I understand]my plans"I be used as public mov da
gg e Licensed Professimul
OWNER-BUILDER DECLARATION
I:' > I hereby affirm that 1 son exempt from the Comsuctcr s License Law for the
S s C following reason.(Section 7031.5.Bunineas ad Rofessions Cade:My city or mun y
w which requires a permit in consbvcl,alter,improve,demolish,or repair any smacture
°•,�' prior to its i.auadce.also requires Ne applicant forsuch#ensu..file aaigrcd sutemem Sq. Ft. FI00r AreaValuatlOn
that he is licensed pursunl to Ne pmvisions of the Connscmrs License Law(Chapter 9 a.
(commencing with Section 1000)of Dbrlaion3ofNe Bateman end Rofnyvibibor.r pNN rnwr2 Occupancy e
So rte is ea5 b anrt6om ad the basis for be ct.to em car,to My violation of S 0 P Y EYP
Section 1031.5 by any.#pliant fora permit subjeeu Ne applicant m a civil penalty of
lot more Nen Ove hundred doll.(3300).
I,.,.wm,efthe prupany,of my employee.with wage::as their solccoreprnsauan, Required Inspections
will doth,work,sod the mucmre is mI imenddoroffered fm ssl.(Sec.1044,BuunW,
and Rofaum loCode:The Contractors License law does me apply to an owner d
property who builds or improve Hereon,and who does such work himself or thmugh _
his own employees,provided that such improvement s e lot intended of offered for
sale.If.however,the building or improvement is sold within me yearaf completion,lie
owner-Wilder will have 0e burden of pmvmg Hai he did not Wild or improve for per. -
pose of sale.),
❑1.as cane,of the property,son evemovely contracting with licensed contncmrs to
moronic,she pmjal(See.704,1,Business sand Professions Cde:)The Contractors U.
cense law does not apply to an owner of property who Wilds or improves Henson,and ,
wW contra¢foretch prnjac a with acodramear a)licensed pursuant to Ne Contractors 'ate
Licentaw. v
El lamun
ex.mptdel SmP
. ,B& Cfm Nrramnis
Owner
se Dem V
WORKER'S COMPENSATION DECLARATION
1hembyaRrmunderpandaofpejuryonceofthefollowingd lmdom:
❑IhavemdwillmeinuinaCmifivaof Cons tmself-insumforWokeriComprn-
cation,as provided for by Section 3100 of the Labor Code,for the performance of the
Which Ihla Formal is issued.
woe have and will munuin Wnrkcrs Compenselian Ed.,'.required by Section31W of the IaWrCme,for the performance of the work for which this permit is hated.
MY Wurkrf})i{", l yjryayrylL comerand Policy nun�r3:_Z&5
Cuter: w•f/IL f! f'Yl/Vr) Policy tic �+1�((J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
Mia section need out be completed if Ne permit isforea ehudred doll.($100)
or 1caa.)
I crnify that in the pedarmame ofthe work forwhich thispamdt is issued,l shall
mI employ any pam m in any monrcr b' t Nc W ompen. '
anion taws of calitomia.Dae
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exrmp' , EWIA
hecnmc subject to the Workds Compenade.pmvisions of the Low,C so
Forthwith comply with such provisions m this pemtll shall be deemed look -
CONSTRUCTION LENDING AGENCY
Q 0 )hereby aRrm that Ne.is a emswcuon lending agency for Ne K..c of
7� the work for which Nis perntit is ismd(See.3091.Civ.C.)
(� Lender's Name
� ' Lenders Addmsn
W EI certify Net I have read thin application and some that the above infonruuon i.
M. z momm,l agree to comply with ell city and caunty.aline....and state laws relating t.
U O building comuucuon.end hereby auHmim mpremnluiven ofthis city,.a er upon the
above-memiond property for inspection Purynses.
W P (We)agree m ave,indemnify and kap harmless the City of Cupertino against
C_) liabilines,ldgmcros,cmued expuw which may in anyway accmeaguast said City
�. W in consequence of the granting of this permit.
0. APPLICANT UNI .RSTANDS AN 1)WILL COMPLY Wit ALLNON-PoINf
f, z SOURCE Rh 11 fI0
Sigumm of Ap a RDOnm Date -
US MATERIALS DISCLOSURE
Will He applicant or futum building cccupaln store of handle hezudous mateual Re-roofs
as defined by tee C.,m.e Municipal Cade.CWpux 9.12,me the Hu1N and Safety
Cora,Section 25532(.. / Type of Roof
❑Yes ai
Will the applicant or future Wilding minted,use equipment or devices which All roofs shall, be inspected prior-to an yy roofing, material being
emit by I'd' ab emomivnuu Ind by the Bay Arta Ab Quality Management installed. If a roof is Installed without >-irst obtainingan inspection
Diavin1 / L"
❑Yes o I agree to remove all new materials for inspection. Applicant
I have read the havrims mormials mamemems under Chapter 695 of He cut- understa and ill comply with all non point source regulations.
toms Health&Safety Code,Segr 25505,25533 and 25334.1 mcersted that if IM
building does nm currudyh 1.....'Z;,is my responsibility to notify Ne occupied
cfthc rtqui r W over poor to issuance of a Centiliter ti p
Signature o A 'cant Date
Ownerora oris a ae '
All roof coverings to be Class"B"or better
OFFICE