00030134 "CITY OF CUPERTINO. PEll No.
BUILDING nrvtstoN PERMIT CONTRACTOR IN +OR+ A+T ®N Q
��INOAl313NESS: (� ,n//,ry�T1 � ooter .Palpla/ 'yj SANITARY NO. APPLIC TION SUB ITTAL DATE
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ARCHITECTtGINECR Sia ik� �O/may �bL NGjPf;RA11T NI;O
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H?i LICENSED CONTRACT'OR'S DECLARATION
ZO 0 y_ 1 hereby aRw that 1 am licensed uMd pmvisiom of Chapter 9L. ug ,Job Description
Qt— wiNSaGon)tluB orDtv'wn 3 of Ne Business and Proteuiom Code,aMmy 1'
1 W BE in full Porce and effect. ,Xy /f{ //�s�/ � 75
Licem<CI G0 V LiaM f/1\'C/// / (/l/,�/ ✓/AV/(./�G/ //G(/f (./]
i<u.� Dau Cwtramr
C Li O gARCHITECTS DECLARATION
j, 1 uMenmM my plans Mall be used u public records
M 'moo Licem<APmresstonal
OWNER-BUILDER DECLARATION
I—Z< 1 bmaby.finer that 1 am hemp,from the Camncus'.License Law for the
following reason,(Section 703 1.5,Business and Profession.Cade:Any city or county
T which"mons. b construct,shut,improve,demolish,or repair any.uuct re,
_ Sq.Ft. Floor Area V'luation
prior to its issuance,also rtgdm Ne applicmtfor.ah Admit bfiR uigned,uumant 1Y'9a'o
Net Me bcensed pursuant to Nepmvisiomor dr Business
Licence Law(Cldptd9 i
(cone he
exewith Section fromtUU)ofbasisfdim rthaliged exaandol.Any violation
or APN N�7uQII1bet 51 Occupancy Type
Secthan,io is exempt any ,if a ,tine nasi.for the n,thn flicanon.Any violation.f �� -U/ "le) P Y YP
Section than five
any applicant for a permiuubjau the applicant to a civil Pendry of
' sed mom Nen Ove hundred tloliw($500).
❑I.m owner of the propeny.mmy employed with wagau Weir seta wmpewtion. Required Inspections
will duties work,and Ne swcturt is trot inti slotimoRened f aids(S..)OM,Beat.
.it Professions Code:The Contractors License law does not apply to an owner of
Property who builds or improve.thereon,and who dose...h work himself or through
his own employed.provided thus such improvements art not intended or aHacd for
We.If,however,the building or improvement is sold within one year of completion,the -
werbuildd will New the burden of proving that W did not Wild or improve for pur.
you of sale.). /
❑1,a ower of the pec.704 .B exclusively Contractile,dei,wed The
contradon to
mn[wct the project(Sec.]04x,Business and Profession,Cade:)The Contratole Li-
who contracts.L.,for each pmjats with aconwdoHOlicensed pursuant to the CantnmMs '
u«sere .w.
Tun excmpr an&r s.. .BBPCfar Nis reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pendry of perjury one of the following declarations: ,
olk I have and will maintain a Certificate of Consent to off-insure for Worker's Compen.
cation,m provided for by Section 3700 of the Labor Code,for the Performance of the s
worjAnr which this permit is issued.
[dry have end will maintain Wnrkels Compensation Insurance.of required by Section
3)00 of the Inbar Cade,fur the performeae of the work for which thio permit iti named.
My WmFj/y�,pcn� ryt,t rea<wrria envy No.: slryhu aoO�U/C_
Came' /,,LL�a�% sent
Panic tic ll/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section neednd becomplexed if thepdmit is forwehurdred dollen($100)
or leu.)
I ccniry that in the pettortertce of Ne work for which thispemut is issued.)shall -
We employ any pawn in any mane,as in,to became subject to the wbid era Cotnpen.
sation laws of Ci lifomi..Dau
Applicant
NOTICE TO APPLICANT:IC afar making this Cenifiwu of Exemption,you should
become subject to the Workouts Compensation provisions of the Labor Code,you must
forthwith comply with wch pmvi.ierns.,his permit shall bo diamond mvoked.
CONSTRUCTION LENDING AGENCY
O 0 I hereby alEnn Nat there its comtnsction lending agency for pMomurice of
z
the work for which this permit is is.aW(Sec.3M.Civ.C,) -
E:, Lenders theme
()G Le. ea Address
W A 'I certify that 1 have nod this application and sum that the above information i,
coned.I agree to .Ply with all city andun
coty oNimce
ns std state laws mg to
z building comtruction,and homby authodea representatives of thus city to enter upon Ne
U O above-mentioned roper,for inspection purposes.
W F. (We)agree In save,indemnify and keep harmless the City of Cupertino against
O V fiabilities,judgment..costs and expenses which may in any way name agdnsuaid City -
�s W in consequcae of tion granun f Nis noir.
[�
APPLICANT UNDRRSTA .COhIPLY ALLNON-POINT
1..) z SOURCE'REGULATIONS
Signatureof ApplicanUContra,
HAZARD ATF.RULS DISCLOSURE
Wnl the applicant or(uturt Wilding azvpent Wore ahaMle hazardous marerial Re-roofs
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cede.Sectinn 25532(el) / Type of Roof
❑Ye. e
Will th<app,;e.nt orfamn paildingo<apantweegaipmmumde.icer which All roofs shall be inspected prior to any roofing material being
not hnandous an consemixtants a defined by the Bay Arca Air Quality Managexen installed. If a roof is Installed without first obtaining an inspection
""'")
Y<s I agree to remove all new m erials for inspection. Applicant
❑ d
IMv<rtad Ne ha ematevl.mgairemmt. chspmi A9saf Ne Cali. un erstand's an Ill with all non point source regulations.
fomu health A,safety C aI ns 23505,25 d 25334.1 utMenund that if the -
WildingdodsedcusrtntlY 0 E.
myrrsposfinfitymndifytheoccupanr
of the remmeme or wh' seance of s Cenificat l3aY
Signature of Appli' ' Date
Owner or authorized agent a¢
All roof coverings to be Class"B"or better '
OFFICE