00080041 '�CEBER &MIT ��
CITY
Py c N COIVTRACIS� T I i1 '1 t 1�: �p p Fj ��
BUR.DINGADDRE 461 PERRYMONT 000
SIN JASON C SANITARY NO. APPLICATION SUBMITTAL DATI
OWNER'S NAMe: (408) 279-1911
NIL CONTROLx
fIONC: ❑
7
ARCHITF:CT/ENOINEHR BOLDING PERMIT INFO
0
Ur I0.
YA/C UNIT
LICENSED CONTRACPDR'S DECLARATION
z 5 v 1 hereby all that 1 sm licensed under provisimu of Chapter 9(mmmeucing Job Description
OG—_ with Section7gp)ofDivision3of,w Bmineuand Profea"om Code.and mY littmcis
0 g in full farcer ec, L({eLic `JJ /rJ/1
W ttnse Class .x
a�,ftJ
s rc CO.VXrIX
H=C ARCHITECTS DECLARATION
I underuutd my plans shall be used as public octads
d z Licensed Professional -7
-7 -73 2 Z 8
OWNER-BUILDER DECLARATION / 1
I— Y 1 hereby affirm that 1 un exempt from Use Contractors License Law for the
i S O following reason.(Section 7031.3,Busimns and Professions Cade:Any city M county
C x which require a pmol,to comtmst,alter.improve.demolish.or routine any swcnue Valuation
3— prior to U.issuamen,9.ouno,s,heapplicantforsuchpermi,toFiileasiBnedaatcment Sq. FL F1Qo9ARD04'1. 00
Natheisllcenwdpunuent,o Neprovisiomofthe C=mXtars Lite wX w(LTap(er9 S tD
(,..ci.SwiMSa0on70W)ofDivision3oftwBusinusmdProfcssimsCede)a APN Number Occupancy Type
that he Ice exempt therefrom and da bud,for the alleged esearpdon.An,violation of P Y YP
Section 7031.5 by any apphcant for a permit subjects the applicant to a civil penalty of 303 — ROUGH EC HAN I CAL
non mom Iban five hundred dollars($5W). 1 I,azmnerof,Mpropeny,ormycmplW=e withwageswNeirsoiccompensadon. 304
_ I 5 e'
wBldolbc wmk.and Ne avunurc isnm inlerdedaoRered(ovale(Sc.7M1,8ualrau 505 — FINAL ELECTRICAL
and Professiom Code:The Conlmcrora License law does ten,apply to an owner of
pmpmy who builds on improves thereon,and who does each wort himself or through 508 — FINAL MECHANICAL
his own employees,provided Na,such improvements are not intended or offered for
We.If.bowe"L he building or improvement is sold withinnce,yeasefcompletion,the
owner-builder will have Ren bucker of Pmvin6 that he did not Wild.,improve N,per.
pOX Of sole.).
1,as owner Of 0a property,am a+cluaively contracting wilt licennd conOctOns m
cons.Ne p jets(See.7041,Business and Profesuom Cade:)The COntrcune.U.
cane law does non apply to an owner of property w W WiWs ne improve thereon,and
who contracts for such prejmts with aconuactor(q licensed pursuant o the Contractors
License law.
1 am exemp under Sec. .B d P C fa Nis aeon /1
Owns
one
WORKER'S COMPENSATION DECLARATION
I hereby affirm arch penalty err perjury ors of the following declernamear
1 have and will maintain&certificate ofcona n co caim
lf- am for Wortcra Compeer- 45
cation,ss provided for by Section 3700 of the Labor Codc,for the parfoma air Of the
work for which Nia pemdt is issued. airr\
1 have and will main sin Workers Compensation Insurance,u required by Section V
37W of the labur Cade,fn Ne peHomtmce ofthe wort for which this pCfmil is issued. O
My Wu s Co P,situ I ro earner and Policy nu�bcrjm,L rJww/
Cama( [icy No: IG
14 CERTIFICATE0 FX Pr10N FROM WORKERS'
COMPENSATION INSURANCE
(This.,inn need not becomplerM ifthc Immil is foronn hundred dol Ws($)W)
Or less.)
I certify Run in the prof.of the work for which this pemut isiuued.I shell
no,employ any .on in any manna w as ro bewon wbiecno On W'OrkeK Compery
ution Law,of Calif mid.Dale
Applicant
NOTICE TO APPLICANT:1f.after making this Certifica a of Exemption,you should
weome subjm,to the Workers Compensation provisions of the Labor Code,you mus,
fonhwit comply with such provisions or this pntnil shall be domed rcvokW.
CONSTRUCTION LENDING AGENCY
Q Ihereby affirm Out Nem is a construction lending agency for the perfomantt of
Z the work for which Nia petmit is issued(Sec.3097,Civ,C.)
Leaders Name
7 Londer's Address
k7 1 certify Und I have read Obs applicaliun and rale that the above information Is
S C comet.I agree to comply with all city and county Ordinances and sum laws re1Nng to
.7 z building loccneuum.an hereby authorise Xpcscnwiva,Of'his city to enar upon IN
U abuse-mentioned pmx,6 for inspection purposes.
IT.
E. (We)agree I sae.indemnify and keep h «, s City of Cupertino agaimt
0 (, liabihlio,judgnr<m costs and expenses which yin ' way aceto&against said City
�. La7 ncomKA,
r+^ting of thispmnit.
r 9 tAPPI.ISANDS AN ILL( MP WITtIALLNON�I NT
V Z SOURONS.
SigvmContncnor D
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle henrdous material Re-roofs
u defined by the Cupcmno Municipal Cade.Chapter 9.12,and!the Health and Safety Type Of Roof
Code,Section 2553247 YP
❑Yes No.
WII the applicant or future Wilding Occupant are,equipment or'devives which All roofs shall be inspected prior to any roofing material being
emit hanrdou,air cdataminwu as deRmd by me Bey Arta Air Quality Mora eounin installed. If a roof is installed without first obtaining an inspection
Di,trict7 I agree to remove all new materials for inspection. Applicant
Yes
ONO .1
Iluve read Ne :,,•doss m.Wnal, ircmena ander Gluper695 of do Gali- understands and will comply with all non point source regulations.
fomes Health aft Cade.B 25 25333 and 8531.1 ondennand that if IN
buildin8d n c 'mlY lout n6 is my mspomibility,on ify ottupenl
oftw req Inch man mop 1 non
atee ofeCmi�q'al
Y �!/ Signature of Applicant - . Date
Owner a mired agent Dale
All roof coverings to be Class'B"or better
OFFICE