00040132 CITY OF CUPERTINOPERMIT NO,
BUILDING DIVISION PERMIT CONTRACTOR"INFORMATION:
no BUILDIN.SGADDDER:ESS /' - �• 253/ GJro��/Q
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V17A�—CHIITCDENGINEER
- SANITARY NOAPPLICATION
SUBMITTAL DATE
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/'`_/vr� isA/j /!//�/� IULUING PERMIT INFO t
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LICENSED CONTRACTOR'S DECLARATION
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0 v 1 hereby affiant Nu 1 am licensed modm
e,provisions of Chapter 9(commencing Job Description
� t-w wlNSecnbn1000),fDlv'IVo 30f Ne Buslmssand Professions Cog mylimnuis
0^.a Q in full rocs and effect - 2
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W.=LL N Dmlc GOn
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ARCHITECTS DDELLECLARATION
cc 1 undeeund my plans shall be used u public recmdn
s ea Unchared professional
LS^_„ OWNER-BUILDER DECLARATION
t¢ 1 h,reby all,.dun 1 am exempt from Ne Contractors License law fm the
E p following reason(Section 703 1.5,Business and Pmfetsiom Code:My city or county
3= whish respircs.pCmlin to e,amm,ilar,improve,dem,fim.,repair am spoors Sq. Ft. Floor Area valuatiUn
prim no its issuance.also requires the su
applicant forch permit to file a signed sidemen �'�( O
Net he is licensed Pursuant to the Provisions M ime the Contractors Llaw(CMprer 9 ✓(lD-
(comnrming with Section 1000)of Division 3 ofthe Busimas and Professions Code)in APN Number Occupancy
Min he is exempt therefrom snd ane the basis for the alleged exemption Any violation of P Y Type
Section 1031.5 by my applicant for a permit subjects the spplicanuo a civil pemlry of
t mom Nm rive hundred dollar($500).
Lanowmrof the properly.or mY.mployses with wag-utheir-11 compcwtion, Required Inspections
will clothe work.andthesmcture is am intended oroHered feel.(Sec.7W,Business
and Profession,Code:The Commcmrs License law it.non apply to m sonar of
property who builds or improves Merton.and wW dont soh work himself or tionAgh
his own emp)oyes,provided that such improvements are nod intended or oNmd for
sale.If,how"
cr,the building or improvement is said within one yemofconmletion,dte
oWm-builder will have the burden ofpmving Net he did not build or improve No pe-
poseof seat).
s
I, i,tuna of the Pm.7uvl.I exclusively contracting with licensed ntraoums i- /Q
onsuucd d project M[y to 0.Bmr of end Profs Wi Code:)The Contractors Li- Q
mon law does nm apply je ts ower of property waw Wilax a improve Caton,and O
who contrecu fm soch pr,Ieca With a ronmene(s)licenced punuann to the Contractors
Licme law.
'D 1 em exempt under Sec. .B @ P C fm Nit aeon
sorsa Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pemlly of perjury tote of the N11—ing dech mumu:
rl 1 hive"will maintain acenifiwe ofcoment to self.mture for Workers Compen-
sation,ser provided for by Section 3100 of Ne Labor Cad,.fm the perfomu«t of the
FOok f, ed.
which Nis Permit is issu
I love and will maintain Worktr's Compensation Inameme,as respond by Section
of the labor Cork,f,the fcrNmance of de work fm which this ptrnll is ieued.
MY Wmker�Coopers—v_iion I tau;{yrin and PoRer mI'V T ?y L..
Cama: �J.K3_ f/ Policy No.: dS '/ JO d/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This swoon need nm be completed if the parent is forom hundred"".(5100)
or las.)
1 certify dal in the perfornmce of Ne work for which this p nal is issued I shill
am employ Any person in my manna so as no become.eubj«t in the Workers'Compen-
sation Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,afar making this CeniEcne of Exemption.You should
her.subject to Ne Workers Compm uti m provision,of Ne Lab,Code.You must
forthwith comply with such provision,or this permit shall be deemed mvoked.
CONSTRUCTION LENDING AGENCY
Q 0 Ibeacby affirm dun Nen isaceomcti,n lending agency for the performance of
Z. the work f,which this permit is issued(Sec.3091,C,C.)
C4 Leaders Name \
(K > loaders Address . �•�'�•'T
ry 1 certify than 1 have read Nis application and eats dot the above infomudon is
1 comet.l egose to comply with all city and county nediromes and state laws reading no
7 L building construction,and hereby amltoTice representatives f this city to enter upon Ne
U O mov.mentioned property for impaction purposes.
4a Fou (We)agree m eve,indemnify and kap haamlee the City of Cupcnino against
O U liabilities,judgments,costs and expenses which Troy in any way acme against said City
fs7 in cm."...of the goosing of We pemth.
_ Ca APPLICAN3'UNDERN(ANDS AND WILLCOMPI,Y WITH At.[.NON-PIIN'I'
V Z SOURCEREGULATU)N
5igron,e of PlicanUContract Date
FiATARDO SMATBRIALB DISCLOSURE
WiII Ne apps son bulking«capon ate.or handle hauNous mancriil Re-roofs
e definedby the Cupertino Municipal Cndt ChapneT 9.12,and the Health arta Safety Type Of ROOt
Code.Section 25532(.)4 YP
❑Yes AN.
Will Me applicant or future building«cupenl use esuipmem or devices which All roofs shall be inspected prior to any roofing, material being
I haardous air conmmiroma as defined by Ne Bay Arca Air Quality Management installed. If a roof is installed without first obtaining an inspection
i^Nai4 �/ I a ree to remove all new materials for inspection. Applicant
oyer ENo
Ihie read the hawdroua mateoiremund
rials resmorder Chapter 6,95 M the cei- understands and will comply with all non point source regulations.
forms Health @ Safety Code.Sade,25505,25533 and 255 W.I undersand that if the,
building d«e mncumn0y haveemrom,Nat is ix mY reepomibilirytonaify da«cu t rx
of the reyuvemmu soh' use b,Ion Flim to iasuence of a Cmitiak''fI is
Y Signature&AMILIs6t Date
Owner or mthor.ed agent an
All roof coverings to be Class"B"or better
OFFICE