00040169 CITY OF CUPERTINO PERMITNO.
,-BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
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BURDING ADDRESS: (�
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OWNER'. 1 xg //�0 E �(/�U/� Y L✓s/ l J
7 NIC CONTROLp
'IANC: � l/LG1P, � C! y59f�S ❑
RCHI fI:Cf?NGINEER �/��- n '/��D/
BOLDING PERMITINFO
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F y LICENSED CONTRACTOR'S DECLARATION
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1 notably arerm that I.m licensed under provision of chapter 9(wmmencing Job Description
W_Cw with Sation)f100)ofD,,yy oog3�flbeBosircse and 'oro jype�aMmYlianseis � ,s' , /in�
E
r.� Utoll fmce ab<RecY'. //) % ✓ter(/,/ /�O (///✓/[/ c t�
Ciccone 1 , lllrrr��� tY uc.«
O U Dem Conaacw
Ior. O ARCHITECTS DECLARA N
f :^ 1 undersand my pIans.hall be uvd v public bosmbdfa
waoo
c
ueert„a Proreaioml OWNER-exemp f DECLARATION
�Y a I herebyreason
e(Tiw that t am exempt s an the Contevmrs License c law for the .
d following mama Permit
b 703 LA Business and ate,derpm Cate:Any city m county
i pooch it,cora permit ro co.des alar,improve,h permit t fie.lrepair any swarm,coure S Ft. Floor Area v/,"/y'�1jtt'f�ly
50
poor miuiuuanceomed to Re,mhetisiom of wlitras for such permit micame gm(Chaptr 9 q
mat he is ilig wiit pursuant m Ne provisions of the a Bell rs License Ides(Chapter 9
that he
la with SeNpen and the
basiion3of alBedareand Pco(MY vi Code)m APN Number Occupancy Ty pe
slut he is a,mq mcrtfrom W der basis for Inc alleged citAlco on.Any violation of
Section them by any bled dont free permit mbjau the appliunOo a civil penalty of •O,�oYr
not more then five omMrcd dollen(5500).
❑1,eheworormrpropeny,mmrempinym,wimwages forml,(Smecompem,enn. Required Inspections
will dothework,andme eConsisroti Lintruse ar dofaer atplyoare Busircu
and property
who
Code:The owe Rumors,
red w Ido sacs rtes apply to if owrcr gh
his own who builds or impmvo thcrmq aha who nta Such wok dad us,m through
for
Ns own employees provided that such improvements ate not inteMd m oR<rtd for
sale.I(hmvercr,me building or improvemem In sold within one yev of completion,the
ow Wilder will have me burden of pmving mat he did nm build m improve for pm-
❑1,as pone,of the Employ.vo exclusively donated-9 with licrmed covmaama to ^/
c naaa U the es not appl(Sacy
7W.owner
of ropand Profession,Cods:)The Conovton. lid
came law dons not apply je m owner or propvry,who bene lir improves Contractors
and V O
who commas for such pmjecu pion a contnaod0licenced pursuant m the Conwcmrs /
Licloow.
❑1 un.scsempt uMcr Sec. .B @ P C for Nis rerun
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of Ne following dcclarniom:
1 have end will maintain•Cmifcate ofComent m elf-imute for Wotkef,Compcn-
tion,as providrd for by Section 3700 of the labor Codr,for the pedomunc,of the
Xwyk fee which this .it is issued.
1 have and will musumma Waters Compensation Imus .v retained by Section -
/J�1IOofIMlaborCode,rtethepafam ,ofd.work fill which mss Permit is issued.
MY Woh nCoypry5gtmypryyfg arnermil Policy twEv�0
Came HTi1 A T///VV Policy No.:—.S
�. CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ration martinet becomp teed if me permit is foram,husdoul"Iner(SI00)
or loss.)
I cenify,that in the d..e of the work for which this panni is issued,l shall
net employ my person in any manner so as to become.eubject to the Woken'Compen-
mountLBW,ofCalifiere .Dam
Applicant
NOTICE TO APPLICANT:IL after meting this C,nificau of Exemption,you mould
become mbject to der Wmkers Compensation provisions of me labor Cod,,you most
fmmwith comply with such provisions or this pewit medl be resonant avoked.
CON,STRUCflON LENDING AGENCY
O 0 1herebyM.that Nen isocom
natction lending agency for the pehm
owce of
Z 2 the work for which this permit is inoed(Sec.3097,Civ.C.)
Lenders Name
7 landeh Address
61I cenify that 1 have rcW this application and sum that Ne above inf.d.is
A. 0 pct.I egme to comply with ill city and county ordinances sed since laws alving to
O Z building comwction.and hereby authmice representatives ofthis city to enter upon the
U O above-mentioned Property for inspection purposes.
We)agree in cove,indemnify and limp Iwmlas the City of Cupanino a0but
O U habilitiea,judgtmnm.ee.and eapemes which may in,ny way accme egaimt win City
in conm mcc of me granting of this partNt.
ti a 0. APPI.ICAN'r UNDE.RS'I'ANDS AND WILL COMPI.y'WI I'H ALI.NON POINT
U St1URC/R"REGUId/TI1)N�^ zlee 4O
Sigmme of pliemuc.ln or Data
HD S MATERIAIS DISCLOSURE
Will me aWddm,acupamameor handle hazvdons mammal Re-roofs
as,defnod by the Cupertino Municipal Coda,Chapter 9.12,and the Health sol Safety e Type of Roof
Code.Section 25532(.)7
❑Ya 1/�^
Will time applicant m far..building eccupnu rex a9uipm,m or devices which All roofs shall be inspected prior to any roofing material being,
out 111:: a a defined by the Bay Ares Air Quality Management installed. If a roof is Installed without first obtaining an inspection
ert7 Y<s {9 N/o I agree to remove all new materials for inspection. Applicant
n Iheve sed thte hnudoua nuarials myuirtmrnu uMu Chapter 695 of tie Cali- Understands and will comply with all non point source re/pprelations.
Famous Health @ Safety Code.Sectio«25505.25533 aha 25534.1 uMernmd my if
buildingdms mtcurrtndy hart emmmenL them it i,my aspamuibiliry m notlfytherei. t 0
of da ayuircmenu whiaB must be ma pnmmiauame ofa Ccoificate f �qrc.
�—/`1—= X Signatu of Applic tet Date
Ower,m sum zrd age Oak
All roof coverings to be Class"B"or better
OFFICE