00040068 OF
CITY
DIVISION PERMIT NO PERMIT No.
CONTRACTOR INFORMATION: -
BUILDING
BUI� O./DRESS
O 3 e(7 ' /�f/W.L/n —iV'�—'mow A["�•...
A ■K/I SANITARYNO. PPLICATION SUBMrITAL DATE
OW MEQ/ Cq�p `/ygB.Q.' � /n l , �/ ^'� NIC CONTROL11
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0.CHITEL /ENGINEER >,> 1ULDING PERMIT INFO ¢
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LICENSED CONTRACTOR'S DECLARATION
o z=e I hereby affirm that 1 am licomed under provision of Chapter 9(commeming Job Description
F=C� with Scesion M000)ofDivision3oftheBmimesand Pm/naionCode,and mylicctue is '
z z G in fall! and d( fi 7 o .<ZXo ZT.+�
l3cenee 6 v_
,�3 to y Dese TS DEC
C:Ca AR Call be toast
DECblicborc j� yY
a� 1 wWersund my Plana e1Wl be uW ss Public remNs " p
Lubstract Pmfn inn "d - u
_
OWNER-BUILDER DECLARATION
t?a T hereby aRmt Net 1 am exempt from the ConsrasCoa License Law for Ne N( �S 2 3 �,R,�•0 /T'
I a C following reason.(Sation-corm�,Busimss end improve.
colons Cade:Any city a county
i3 which rtquves a permit m canwa,art improve,demoliN,or rcpsir any swcsure Sq Ft. Floor Area Valuatioan}�
thatheor slicmancgamnt in iesthe thosisiocant fonmhpemuuaicensat,ae Law(Chapter
�3 CM Jd SOQ - {J
Ruthelalicemede,also pursuant in the pmvisiontsof the such ermit o feneelawl state a9 i�L�/
(cammcncing with Section 7000)of Division 3 of the Business;ad Profanimt Code)m C
thinheis exempt therefrom anal the buil for On alleged exemption.Any Anhui.of APN Number 1 Occupancy Type
Son 7031.5 by any applicant for a a permh sub*ts she applicant to a civil penalty of 3 0,7_ 30 _
9- 3 0 -a0
n n more then five hunNed dollar(5500).
❑I,awownernrtheproprnr.armiempinyenwiNwagnnNev.metnmprcraiov. Required Inspections
will can the work,am Ne arrow moa is ins immdod ordremd for In(Sm.1014.Basimrs
.it Profession Cade:The Contractor's License taw dors tortapply to an caner a
proprny who Wilda or impmvea thereon,and who alas such wants himself or t1rmgh
his own employees,pmvkhal that such improvements the not intended or offend for
We.If.however.Ne building in irnpcovemem is sold within oro yearof cantileuon,the
owner-Wilder will have she burden of proving that he did not build or improve for par-
fameofWe.). �.
L,at owner of the propeny,am exclusively contacting with licensed conveetoss to
construct the project(Sm.7044,Business ad Prolessiom Code:)M Coneem a's V.
crowe Law alas not apply to at owner of property who Wilds or improves thcrzon,and /7C
who contracts fa such M*B with.conra or(ij licencW panoarm to Ne Co on,ars s
ec
n law.
0
1 em exempt utiles Sc. .B&P C far Nia rcaan
Owner Date
EC
WORKER'S COMPENSATION DLARATION
1 hereby affirm under penally of prijury one of the fallowing da erainn;
❑IhaveandwillmainWna CcniflcaseofComenuosalf-insumforWaher'aCompton-
tion.in provided for by Section 37M of the Labor Code,for the perfomance of the
k for which this pemtit is issad.
1 have end will maintain Worker's Compensation Insane,as required by Section
My
Wcarke la Code,fa Ncprhat, of Nowork for wM1i<h Nisprm,it isinued.
M Carrier
n_ Insurame c5=1he Polity tsumbv a3O e2 s
Carrico /✓fnt'ga•RI Policy No.: WORIU iYd
CERTIFICATE OF COMPENSATION INSURANCE FROM WORKERS'
COMPENSATIONINSURANCE
(Dris section neetl not becwnPletedifNe pemdt in foromhundrnd alalias(SIM)
a los.)
(certify that to the my
of the homfor which this thepermitisissues.lshall
not employ any penton in ani manner m n to become subject to de Workers'Compere
session laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Cenificaa of Exemption,you should
became mblest to the Wako's Compensation provisions of the Labor Code,you must
faMwitb comply with such provision or this permit"I be dcemed revoked.
CONSIRUCr10N LENDING AGENCY
QQ IWreby affirm thea Nem is a entucuon lmding ageey for Ne performance of
Z Ne work for which this pecmit is issued(Sec.3097,Civ,CJ
(.. LeMeer Name
a ? Landers Addrtn
It.
0 I cmify rhes read this have rthis application end awe Na the above information is
cartes.I same to comply with all city and county oreli ones and sum laws relating in
U 0 building contraction,end barely mixed.representatives non,city tomam upon dm
abnve entioned property for inspection purposes.
(i F
(We)agree to wave.indemnify and keep hamlen the City of Cupertino against
O U behilues-jndamoma catsand expmsea which may in any way ii.me.9mot said City
} W in conwcgocwm of its,granting of this permit.
r N APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALI,NON-I'OINr
SOURCE RF (ATI A .
a� —�i�v
Stgrtam of Appho C`mmIm Da¢
FD3TARDOUS MATERIALS DISCLOSURE
Withy the
Municipal
Cemcopentamrt2.handle Hart melena RFrOOfS
C defined io Ilse 32(a)?no Municipal Code,Chapter 9.12,and the Health end Safety Type Of Roof
Codc.S«cion 23532(e)M
❑Ycs
Will'be applicant Orfuture Wddng«xupenluse rempmemardevicaswhich All roofs shall be inspected prior to mit any roofing material being
emitict? us air conuminnuesdefinedbythe Bay ArcaA'v(?.WiryMavagevam installed. If a roof is Installed without first obtaining an inspection
ehind
Z]Yes fig! I agree to remove all new materials for inspection. Applicant
th
Ihave,r, ahn,,,nenrustnes,apt,irememtsnnde,Cnaprr6.95ofthe Cat- understands and will comply with all non point source regulations.
fomu Health @ Safety Code.Section 25505,25533 ab 25534.1 mararead that if Ne
la,4.h d«syyyyyyacu I hevcatne 6thm is is my responsibility a notify the atopens s
of Nen wN ymun be prior io issuance o(aCrnifcam of OccuTancy. ` `QO
owner r.alnoyW.gemrSignature ofXpplicant Date
Dan
All roof coverings to be Class"B"or better
OFFICE