00030102 CITY OF CUPERTINO PERMrr No.
ttmLnwcnrnstoN PERMIT CiTR ACTOR I' FORMA IOO ' 000 15 O l0
HUILIANGAODRESS: p'
I I I D 5r6e z= CC LANE SANITARY NO. APPLICATION SUBMITTAL DATE
fS'ER'S NAME: /^� gR T VoRA +
gN `N�� NIC CONTROLp
ARCHITECDENGINERR .#�' '�vl�' i`DU4OING�gERM'I; Igltip
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LICENSED CONTRACTOR'S DECLARATION '
I hereby affirm that I em licensed under provisions of chapter 9(commencing Job Description
P_Fw in NSecrc.sun00)ofDivision3oftheBmimssaard Profuaiom Code.cad my license is
YasJ infellee].alld efftcl
eco Idcuec CIaM Lic.N
Can tor
o Date ARCHITECTS DECLARATION I W l g t 1 d L
aI I undetetand my plans shall W usedu public records
m O Licensed Professional
c u7 OWNER-HUB.DER DECIARATION
t?< I Mrtby ePomr That I am uemq from the Contractu
re eLicrnse law for Ne
ceRO following ruin.(Section]03L5,Business nM Prefeuiana Cade:Any city a county
m which reclaims a permit m canveucl.alter,Improve,dens ish,Or repair any structure
n,3 Sq. Ft. Floor Area Valuation
pdmtoits iawance,also recluirts Ne applicants for such pemJlw Bleedgned nodemem / b0O1 �S 0
that he is licensed pnnuantto Ne provisions of Ne Conuanafa Licence Lew(Chapm9 (p (�
thammanciegaintheemnmoo)afomiiiafarOnaleadnearandProAnyvitim.of - phi Number Occupancy Type
that he is emmpt therefrom eaM Nc basis far Ne alleged caemption.Any violeum of Q p y yp
Section 7031.5 by any applicant fora pemtlt subjects the...licamn...ivil penalty of 3 5 I 03 6
not mom Nen five hundred dollars($500).
*pg Lora owner of the propeny.ar my employees with wage.as Keit selc cempemalion, Required Inspections
I do Ne work,and Ne ewctwe knot intended m offered for ark(Sec.7060.Business
and professorate Code:The Conoactorr License Law does not apply to an owner of -
pmpmy who builds or improvu Merton.and who does such words himself or through
his own employers,provided that such improve...am me ieteMed or offered fm s
sale.If,howevcc the building or improvement le sold within ams ynrafcompletian,the
owner-Wilder will have the tandem of proving Nat be did nut build or improve for Pur-
poseofu.e.).
❑1,u natter of the property,am exclusively contracting with Recoil contractors to
comuuct Ne project(Sec.7060,Business and Profession.Cade:)The Contractor's Li-
came Law does amt apply to an owner of property who builds or improves thereon,and -
whocuntmcts for such projecte with a comactmts)licensed pursuant to the Contractors /
License Law. �g
❑la c.in,mir ' BRPC Nis cmOw. VI/1
171v�1/LGA..�.1/ Dam 0m V
WORKER'S COMPENSATION DECLARATION '
1 hereby affirm under penalty of perjury one of the following dec.aaetiom:
J.have pro will mdntdn a Cmidam of the
Code,fort for Worker's ce of the tion,r provided fid by Salon 3]00 of Ne tabor Code,for the Performance of the
(-rocs for which this pndr is issued. '
_ 37 I have cad will maintain Wrrkch Cance of Compensation works
for which
h required by Section
MY ofthe labot Codgfd the pctfofmanceof Ne work for am: permit is issued.
MY Worker'.Comprnutian Inmaantt eertia and Policy number arc: -
Ganm Policy O
CEf1TIFlC O OF COMPENSATION
FROM WORKERS'
COMPENSAT.ON INSURANCE '
(This merino readme becompleted if Jae permit is Forane haedrtJ ddlare(SIM) -
IXlu.)
I certify r in the peffmee of the work for which this permit is issned 1 Mel.
pe
amt employ any person in any manner as become subject o the Warken'Camper.
cation Lawe of California.Data
NOTICE
Applicant
NOTICEubj APPLICANT:If.aftCo pensati Nis Certificate a o/Lampton, .y should
st
become subject y the Worker's Coon,in this
pmvisihal of the Labor Code,you man
' foMwiN comply with such provisions d Ni.peamlt shell be deemed invoked.
CONSTRUCTION LENDING AGENCY
Q I hereby amt than there is acomtrucdon leading agency for the a .of,
thework fm which this permit is issued(Sec.3097,Civ.C.) _
Landers Name
7 Leder.Address
Lal _I certify that 1 have read We application cad codes that the above information is '
Gf z correct.l acme to comply with all city and county ordinances and sum laws reining to
V O Wildingconstruction.and hereby amhdiremprevrnwivee of this city to enter upon the -
.Wv'-.mi.ned propene for inspection purposes.
W [ti (We)agree to save,indemnify and kap Inflation the City of CupeNno agelnsl _
V linhi.iues.judgmeme,cants and eapenms which may in any way eccmeegdnsl said City
in consequetRc of the gmnubg of this permit.
F` 0 r;4 SOUAPPLICANT UNDERSTANDS AND WILL COMPLY WITI I ALL NON-POINr
f..l RCE HP LA'I1f1NS.
ll. y ks..-4
Signature of ApplicanJConaacror - Data 3�
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore Wilding occupant store or, hazardous material
aa defined by the Cupenino Municipal Code,Chapter 9.12,and to Ha dth and Safety
Coda Sion 25532(0] Type of Roof
❑Yes ?tNo -
Will the applicant or future Wilding occupant use equipmentor devices which All roofs shall be inspected prior to any roofing material being
emit beurdoua a4 contaminann u defined by the Bay Amu Air Quality Management installed: If a roof is installed without first obtaining an inspection
"""' I'a agree to remove all new materials for inspection. Applicant
❑Ye. I¢Na - .. g P PP
understands and will comply with-all non point source regulations.
1lure mad the hazardous suras 255 5.M53 an abler 1.I 6.95 W at Ceti-' P Y P g
fomu Health n Safety Code,e a tens 25505,35333 end 25536.I tordvnmth that if Ne
Wilding does not currently haveamnunl,that it is my rtsponaibilirytonmify the occupant -
clavif Nym�I ity�grte whop m f be met prim m icauarce of a 0,011 9t of Occupemy. '
er
1..v.r 4 /o o Signature of Applicant Date -
Owner ar cuJwrized agent m
All roof coverings to be Class"B"or•better
OFFICE