00040176 CITY OF CUPERTINO PERMUNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: D O0 4 O r
1
BUILDING ADDRESS: c
a IZta STAFFOR DRtVp SANITARY NO. APPLICATION SUBMITTAL CATI
W NER'S NAME:
Air, 40 If, ML-E -r—S rJ Owed« NrC CONTROL«
ION-: ❑
y�8-366-1215
ARIIHTECDENGINEF.R bULU1NG PGIiMI'I INP(]
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I_ LICENSED CONTRACT'OR'S DECLARATION
F_zo„- cim7 ).f wll Sof the asslBti under Provisions P; frvai r Code.an(crmmeaiag Job Description
I_w wiNllfew.9000)of Division 3of NeBn,inen WProteuions cove.and my license is
.a< in forcesvd affect.
ul Date Class C .M
Ok!u. Deg Cmmc'.r FILLI hI (n l� SWlMMInt Lft (BOOL
C u.OARCHITECTS DECLARATION
I
undentard my plans dull W used as public sada
a Y Licensed Rofeuion,l
OWNER-BUILDER DECLARATION
I-t r 1 bereby drimr Nan I art.excmpr from Ne C.ntramYs License Law for the
ce F o following reason.(Section"ro31.5.Busir s5 W Prof ion,Code:My city or county
which"tium a perni inWnalmct.ahg lmpmv,demnhah.01 repair say aW=tWe Sq' Ft. Floor Area Valuation
3 prig do ns isauana,also rcquirtsthe applicentforauch permit do fileasigned augment r
that he is hoeovd Forward hu the provisions of the Counecoes License law(Chapter 9 6.J tT0
(commencing with SmdW t000)of Division 3 of the Business and Pmfesaims Cade). ppN Number OCCU anc Type
Nat he is event,du refrom and dw buia for the alleged emniplim Any viohum of �•'�. O 7_ P Y YP
Section M31.5 by any applram for a pemdt subjar the applicant ...ivil pawky of
pt rt Nan five hundred dollen(5500).
awrsa.rNe property,are my employes with wagam Ncir cote eempen,ad Required Inspections
w it l do the work,and Ne structure is nod intended cr offered for sale(Sec.91M I.Business
and Proposal.Code:The CWwwwr'a License Law door scot apply to an owner a
property who builds or improve thereon,and who does such woh himself or twough
W,own employed,provided than such impmvemenu in,nm intended a aRcred for '
sale.If,however,the building or improvement is sold within one year or completion,the
ar-builder will have thc When of proving Nat W did nm Wild or improve for pur-
pose of axle.)
1,u owner of the progeny,am exclusively contracting with licensed contracmn to
emerwd the project Soc.7)40•Business ud Profession,Code:)The Conaacmis Li-
cena law dna noupply to are owner of property who Wilda or improve-hermit ud
who contracts for such projecta with a cmuecsars)licensed Pursuant'.the Camractots
Licence law.
1 un caempr uMcr Sec. .B R P C fa Nis sterns
]wrier J-4i --^--�' Dag O/^
WORKER'S COMPENSATION DECLARATION
1 hereby a/fnn under penalty of perjury We of the following daluation,:
❑I leve and will maintain a Certificate of Consent o wif insure ra WorkefsCompen-
s lim,as provided for by Secuon 3700 or the Labor Code•for the perfomunce of Ne
I work for which did.penni,is issued.
1 hove and will maintain Wnhcra Compensation Imusau nce. recurred by Section
3900.(the IaWr Code,for the performance of Jac work for which Nis permit is issued.
My Werkdm
s Compea
tim Insurance curia or
and Policy number e:
/ Carrier: Policy No.:
CERTIFICATE OF EKEMPr10N FROM WORKERS'
COMPENSATION INSURANCE
(This satins need nm W cumPleted if the pens='is for one hundred dollen($1 W)
.leas.)
I«miry that in the performance of the work for which this pemtit is issued,I shall
We employ any person in any menar an,as to become subject to the Worker'Compere
swim Laws of California.Dar
Applicant
NOTICE TO APPLICANT,if,after making this Certificate of Exemption,you should
becon.subject to Ne Work ,,Compensation provisions of the Labor Code.you muss
forthwith comply with such provisions or Nis p.it shall be damW revoked.
CONSTRUCTION LENDING AGENCY
0 I botchy alErm Nn chert is a construction lending agency for the pertomurce of
L 2 the work for which this permit is issued(Sac.3097.Civ.C.)
E. IaMe/x Name
lender' ss
s Address
L�a7 — I testify that I have rad his application and area Out the above infomutian is
C. erecv I agree'.comply withall city and county adivnus and sac laws reWing.
7 z building construction,and herchy amhoniu repreanatives of Ms city to enter upon Ne
C.7 C above-mentioned pro,.,for in,pecuon purposes.
W. tw (We)agree to save,indemnify and kap harmless the City of Cupertino against
V litestitid,jg ownts,costa and expenses which may in any way acsueagainu said City
^w '
g] n cWwru nce of he gmming or Nis permit
E" 26 APPLICANI'UNUERS`fANDJ AND WII.I.COMPLY WI I H At.].NONdroIN"I'
f..) z JOUNCE REGULATIONS. aa�
Signature of AppliceHAZAR ct. Dag
HAZARDOUS MATE RIALS DISCLOSURE -
WillJgappl¢end or future Witting.ceupent sure or handlehazartloua material Re-roofs
as defined by the Cupertino MJType of Roof
Code,Section 25532w)'I .✓J es No
❑Y0Ye, applia.tafwdwa W;lding«=wpantwgegwipm stored ,;=e,whi=h All roofs shall be inspected prior to any roofing material being
in hawdous anconuminms as defined by the Bay Arca AU Quality Mnagount installed. If a roof is Installed without first obtaining an inspection
'ante° I a ree to remove all new materials for inspection. Applicant
❑Yes �No g
la nredN h actor amagti are9wirea g and relapse b95afth e.i- understands and will comply with all non point source regulations.
Forma Hd1th a Safety Code.Sectims 255(15.25533 and 25530.I understand that if the '' '
I Wilding dnot '.ncurrently have a caner.Out it is my responsibility ratify the occupaa ay�ywwa��
.file"a untions which in 1.x met pd.m iavu.ae of.cenir<.a rr q==p.�aw
_ 3 4 2'1/ren, Signature of Applicant Date
Owna.Wdhwwedagem Dag f"`
All roof coverings to be Class"B"or better
OFFICE