00040025 OF
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DrERONNO PERMIT CONTRACTOR INFORMATION: 00 O gONO2S
S: SANITARY No. APPLICATIONSUBMITTALDATE
or� � p2 .4a �.S flwto
a/-y 0/- �/S N. N,CCONTROL»
9 -�7g9 Ar /9,5081 ❑
NITELm/r.NGINEER BIiLDING PERMIT INFO
o 0
F�-7 LICENSED CONTRACrOR'S DECLARATION
zoy 1herebyaRrmthatIamlicensedunderprovisionsofChaper9(commemi.g Job Description
°O_�9 widiSection]OIIB)ofD,,omn3oftheBusinessnitProgammoCCodc.andmyii«n«i• �ys�RLL 3a� �AFr ��( i �°ATip ) YCLo$i�Lp.�
6 Y i O fullroae/nit ef« Q
3 LL O loran/r�s'1„• nLic.x
Date U�r�.J Cost
SDELL
O g ARCHITECPS DECLVtAT10N
y 1 undratW mY Plants.hail W used u public recada '
a � # PIC(--
5/
w a�o Lir«eed Pmreaainnm )L66 �$
c OWNER BUILDER DECLARATION
t < 1 hereby affirm that I am exempt from the Cmnractolrk—
s License Lew for the Y �rO 1
f ❑ following reams.(Section m31.5.Business W Profhasion Code:My city«county -
dwNch aquvu a p«mit W conhuc4.Ince,improve,demolish,or repair any smxnurt
a_ Sq. Ft. Floor Area Valuation
prim to its iuusnes,also"aims the applicant f«such permit to Ne a signet statement
(commencing
commecpuauant rods Of Division 3 the Conte dolsndce flaw(Chaia)in
dust heenn:ixemitres«donmadchat, igfrm alhe legedexemption.pton.Anyvneeae)of pithN ber Occas ane T e
Saidshit. is exempt any mph and ds basis for the allyed exemption.Any violation.f P Y YP
W,assn eth n sae any applicant for.permit solicits the epplicanno n civil pewlry of ) ~DO
pW,come than eve nunenea delft,»155ao).
I.as.wren.rthepi.xtty,«myemploy«swiNw,gasasthevaolaamnpcna.ti.n. Required Inspections
wBl de the work.W Nesmsture is not mounted urofeml fm We(Sax.7W.Begins.
aur Profession d:T1s CoConuactor i License law d«s rwr apply to m w«r,of
propany who Wilda or improve.Nerenn,W who does such work himself or through
his own employer.,provided that such impingement,as am intended on,.fared for
saft.1fhow wt.the Wilding or improvement iwithin one
year fcompleron,tM
wncnWild:lwill have
seburn fprroving that
he did not iieinmproveforpure
yu
'Ol/♦
of We.).
�Q
i,as vwesercr of the property.em exclusively contracting with livened convxtnn m -
tom uct Ne mi.(ger 7044,Bu.imu and Profeuion Cod:)Tne Cowecme.Li- O '^
cert taw does not applyto an mgm r of property wW Wild..,impaovn thereon.W
whit contncts for such p cimig wish•oonuacam(.)licemed punusem to the C.nhauole
License law.
I am exempt under Su. .B k P C for this reason
owner Data
WORKER'S COMPENSATION DEAT
CLARION
1 hereby afrimn uMar penury of perjury con,Of the following declaration:
I have aM will common.•Camara.ofc..t..s ff-inure f«Wmi els Compcn-
ahen,es provided for by Section 3700 of the Lido,Code,for the amformsoee of the
«which this permit is issued
w. ,
1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the V Wr Cod,for the perfomunce of the work for which this permit Is iamed.
My Wodre(yfym nInsu er end Policy s7 st�22
Certiu:�/�/4 H[/ecem Policy No, /�]�/
CERTIFICATE OF EXEMPTION FROM WORKERS' ,
COMPENSATION INSURANCE
('oris section needsit he e.mple¢diob, amnif is turn«huMWd dollars al0g))
or 1«s.)
Icendylhnin Neperformeaceofe ssurtfu'u, thispematisieeued,Isholl
nm employ any��ss "any mann r peyome.subject to the Workers'Conal
tion law,RCeXf, 4I/
NOTICE JeKrqT.If,after making this Certificate of Exemption,you should
Mcome subject to the Wedge's Commination piovision,of the labor Cod.yet,must
ronhwiN comply with such provisions or this permit shall W deemed revoked,
Q CONSTRUCr10N LENDING AGENCY
Q I hereby uffimtrrw there is.construction lending agency for depermmuseeM
z M work for which Nis pcmat is issued(S«.3097,Civ.C)
Fh Lerdrea Name
" > landls Addeo,
WI unify that 1 have reed this applicalten and awthat at the above information,is
0. Q covet.l agree to comply with all city and county ordinances W state laws relating to
D z building conswction,and hareby amhorl«repic.anutivaa.f.ho city to enurup.n Ne
U eWvumcmmund property for inspection purposes.
(We)a,,«to ga,indemnify and kap home.the City of Cupertino grim
0 U liabilmax.judgmenu,cnt,W espansu which mayor any way socrueagaint said City
} W in coneequeoea of the 9.61.1'this permit.
i 0e APPLICANTUNDERSfANDS AND WILL COMPLY WI'I'It ALL N/0' l r
SO
fA JZi,RC tm y]
I D. A9,0101096
HAZA lift— MATERIAlandgoLS -Medi
OSURJE
Win the.ppW,nt«rmme Wilding«..pint nn««nWle naasrdnn maao.1 Re/04's
m defiW by the Cupertino Mucci c.Chapter 9.12.W the Health W Safety T e of Roof
Code.SectionM532(O7 �/ YP
El Yes pin
Will the applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
udotu atr counterman as da by the B.y Are.Air t�Wlity M.n.gemann installed. If a roof is Installed without first obtaining an inspection
" I a ree to remove all new materials for inspection. Applicant
•w(]Ya o
I have resd du huarduus materials reyuiremanW under Chapter 6,95 of ds Cali. understands and will comply with all non point source regulations.
forma Health A Safety Code,Scitiona 25503.21x33 and 255;W.I undusWnd that if no,
building does not comently have a tenant.the it is my rtaponsibility in no ry the oceupent
of the�wu �W pour m issunn«of•Canif9�t r upency.
Signature of Applicant Dale
Ow De
All roof coverings to be Class"B"or better
OFFICE