00050144 CITY OF CUPERTINO y �-,C PERMrr NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION-
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BUILDINGADDRESS: /�,AsemQ
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ARC]iI'1'IiLT/IiNGINEER �f0b �`�O _o^�S_�_ BULUING PERMIT INFO
0_OF I O Zl sJ
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F LICENSED CONTRACT'OR'S DECLARATION
i o vi- 1 hereby af.Nat 1 am licensed ueder provisions of Chapter 9(commerriag Job Description
Cmt-w with Session ndaffefDiviaion3oftW Budnevv nW Rofeviou Cade my li.nseia
~ p�
�xrd< Licen.omc W<Becs 2 /j_ P✓ syl/fc/l Oft/ s
S C W C Out Class Co 2,
Out u7' / Y
Dem C S DECIr
F•t.C g if lf ARCHnECTS DECLARATION
v�y 1 understand my DINS shall be used as public reseed,
W
a.u. C Licensed Professional
aped OWNER-BUILDER DECLARATION
f-Z a 1 hereby affirm mel 1 am exempt from Ne Contractors License Law for the
+�r O following rcuon.(Section 7031.5.Business and Pufenions Code:Any city.county
which Yq e t m C.ct.Cher.improve.demmllvh,or R an aWCIIVe
'�" pe "'fim vin y Sy. Ft Floor Area Valuation -
thiortoitsiRuedp alsom.rho the applicant for such permit Lfilea Lamdeumment
thataniscogwis puswm tot )provisions 3the cousins Licenselaw(Ciupt).
(commess exampNseetion and
basis for of theBusinessexempton.Aand ny
Code)or APN Number Occupancy Type
that he is e.mbt therefrom yapli aut Ne buil for the elkged enemant to a civil
violation of P Y YP
Sections,than five
any aped doll for v pemdt subjects Ne applicant to a civil penury,of
pm mart Nen Ove hvnn, dollen y rue'.
I.aamwmerartWpRperty.mmyemployee,withw.gmat,chair aolernmpemutian. Required Inspections
will do Ne work,and the swcture iv nm imrndeduroRcrcd fm We(Sec.ltXx,Buumu
ped erty whiou Code:The Conracmr'v,and w Law dam rot apply lf owner nd —77 -73
S 7 -7 3 -Z ,S 63
property Pro who builds e:improves ucan'. and who does such work plytohimself m through ( ( L Q
his own employ.,,provided Net such improvements are am inmMed re offered for ^f 9 /
We.If.however,me Wildingm improvement is sold within one yeuofrompletim,the `
roarer-builder will hart Nc bander,of proving that W did nm Wild.impart fm par-
pose W We.). -VQ
1,as owner of the Draper%am exclusively contracting with licensed common to
same Law
project(See"lana,owner of sed, ladmaswho Wilds
Cade:)The es themoi. fid
Ll-
same law d«v not appy m an owner m propny who Wilda or imputes Merton,and ES
who contracts fp inch prolec.with a cono-actatfq licensed pursuant m the Contrecmrs
License law.
1 em aempt under S.. .B&P C fp mice recon
LeS�
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of me following declantiom:
Iheve mtl will trWnWnaCenificasc ofCRuens so self�inwrtf.Workers Compen-
ution,u provldW fp by Secdmn 3108 of the Labor Code,for the pertonur,tt of sM1e
work have
ward this permit is issued, D
❑1 have and will certain i Waters Compensation Imuzmcc,u required by Section
3700of Ne Labor orkerrCCcove�.f.the per(ormyanmce ofdo work for which his�permit u iseued.
um
CvmVcr.1 Pr,-f"f "m4Vn /J Polc Nlo.:
E-f ERTIFICATE OF EXEMPTION FROM WORKERS'
COMP IN- SATION INSURANCE
(This vection hared nor W completed iftha permit is fords,hundred dollars(SIM)
or ks,.)
I.nify Nat m the perfarman«of the,work for which this permit is iuued,i shall
not employ any person in any roamer»aroWcamewbjecuothe worker(Compo-
ntion Laws of California.Dan
Applicant
NOTICE TO APPLICANT:IL after mmking this Certificate of Exampdo dyes u.11
Wcomc subjut to it Wodars Compensation permit
of the Labor Code.you man
foMwith comply with such provisions or Nis permit shall W deemed rcvokW.
CONSTRUCTION LENDING AGENCY
Q 0 I hereby bra thin NCR ise combustion lensim,ageocy,for the performantt of
Z. the work for which this
pemtit is iuued(Sec M17.Civ.C.)
F., Lender,theme
yet 7 T<tMer't Address
Lr,7I cenlfy mu I have read this application and aMe Nat Ne vWsa information is
0. Qcorrect.I agree to comply with ell city aM county miim nos and sR¢laws Rlning re
.�. Z Wilding comstuction.and WRby authoriR representatives of this city Rcnnr upon Ne
U O eWsr.ot mioned property for inspection purposes.
s E., (We)agree in save.indemmdfy and keep havmleas the City of Cupertino apimt ,
Q U liabilities.judgments. as.and expenses whichrea,mmy way eccut, mmi aid City -
in comequcmc of the gumting of this psmit. _
'r 0. APPLICANT UNDIRSIANDS AND WILL COMPLY WITH ALT.NON-POINI'
U L SOURCE REG ULKI'IONS. o
Signaboa Applicm ntn snr late
H, A.P��,,U. ATERIALS DISCLOSURE
wntlrc.ppucantoCfuture Wilding.serpent suxe.nWle lurvdoaa maters Re-roofs
u defined by t W Capenina Municipal Code.Chapter 9.12,emW the HeaIN and Safety pe of Root
Code,Section 25532UTy
)1 r J
Dyes C:]No
Will the.,licut or future Wilding ocmupmt tae equipment or Ccvkm which All roofs shall be inspected prior to any roofing material being
azbdous air contaminants as refund by to Bey Arca Ah Quality Mmagcmrnt installed. If a roof is installed without first obtaining an inspection
?ya, No I agree to remove all new materials for inspection. Applicant
h. heads ft h.adeousmria.regtirem n.aM rGMpmb.93nfdrGili. understands and will comply with all non point source regulations.
\
f6rni s Health sk Safety Cade.Sections 23505,25333 and 2553x.1 underhand Net if the
Wilding draw not currently have en L thus it is on,responsibility to notify dn�cccupft
I
't of the re—yo . mu et piw so issuance of e Cmmfcue mfpc , �w Signature of Applicant Date
Owaro utlmnzed agent Data
1 All roof coverings to be Class"B"or better
OFFICE