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00080052 ;ARCHITEC'UENGINEER ITY OF CU _N _. - PERMITNO. BUILDING DIVISION PERMIT CONTRA CTQjNFORfiVMATION: In8i08i2000 BUILDING ADURFS SANITARY NO. APPLICATION SUBMITTAL DATE (408)365—^2058 ER'S NAME: NIC CONTROLp NE: IULDING PERMIT INFO ❑zz RE—PIPE LICENSED CONTRACTOR'S DECLARATION O z_ h mby eR m Nat 1 as (leaned u d r provisions of Chepar 9(comtmneing Job Description Fay_; with Section 70004o1'Divisiun Sof the Business fuuom Codef,W' mylimeu HRinfullforce and<Rect LicCT'SDoARCHITECTS DECLARATION d y 1 undeuuM my plans shall lanced n public records .0 a. licensd Professional c OWNER-BUFLDER DECLARATION $ (=z G 1 hereby affirm than I am exempt from the Convector',License Law for the dZ e folly'ng rcnon.(Soction 7031.S,Business and Professions Code:Any city m county am which requires.permit to comtron,0-1 improve.demolish.he repair any asset Sq. Ft. FIfTWhi?6054. 00 Valuation prim wits isavancc.also requires the applicant for such Permit In Ell•signod,utemem Net he is lienal parmand to the provisions of the Convacmre Lieens,Iaw(Clapan9 (cummen exemiNSection7(100)or Divisionr the alleged cssoM.n.Anyonilmon)or APN Nteftr — UNDERF _OOR PLLOWLTINRY Type Nat m is exempt Nanafrom ane th,basis for Neo, eacmpion.Any ns Co b of Section 70315 by any applicant for a peanut subjats the applicant to a civil penalty of 301 — ROUGH LUMB I NG net more Nen five hundred dollars($500). ❑1.atmwnerorthpropny,army,mplo .withw.getatheir.olerompnsatian. 502 — ENERGY wdl ed the work,and the structure lana intended or oRened for We(S..7044,Door . and Promances Cade:The Contactor.Lime Law does,aol apply to an owner a 507 — FINAL PLUMBING property who builds ar improves thereon,anal who does such work himself or thmup his own employees,provided than such improvements tic not imended or ofersd for We.If,however,the building or Improvement is sold within one year.(rampletion,Je owner-budder will hove the burden of proving that be dki not hild ur ion ove for pur- e of sale.). i u owner ij the pmp7 .Business urincischit'vidymal convecting with hcaned convactou to / Li- or. U the esor,(Sec.91w,wner of rope property oh i Wi Code:)The C,thermal. ml.Li- come law does...apply je t,oath.of Fra tors w1e builds or improves Corton,rope who contracts for such polau with acanvector(s)licen,ed Pursuant m the Canvectof, 0 1 mr,law. ❑1 am cacmpr under Sm. .B At P C for this tusan O^ other Data v WORKER'S COMPENSATION DECLARATION Rrm pMer 1 hereby aFamily of perjury one of Je following dashostiom: I have aM will maintain a Certificate of Consent o stl6insnre for Worker'sCommon- sation,as Provided for by Smum 37M of to Labor Code.for the performance of the work for which Nis permit is issued. n 1 have and will mainum Worker's ComPenaatien Itnmence,u required by Section 3'100 of the lobar Code,fn de performance of the work for which this permit is issued. My W e C emau r tt a and Policy n art' Cenicr: la u Policy N.,.,��/0� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This.wcuon read nm be completed if Ne pemdt is forces,hundred"(.(SIM) or lest.) I certify Wt in the performance of the work for which this Noun is issued,l shill rot employ any person in any meaner se in,to become subject to the WorkenCompen- ntion laws of California.Dau Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become aOb*l to Je Wortrr'a Compensation provisions of me labor Cade,you must foMwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY R z 0 (hereby atm that there is a camnrcuarre an loading agency for the Porformof z ythe work for which this peril is issued(Sm.3097,Civ.C.) Lenders Name [� > lender's Address LT: 1 cenify that 1 have land this application and sone information the above infoution is d 0fer.I yore ro comply with JI city and munry ane ecu¢ dinume,alaws reining to Z rebuilding construction.and hanebyeuthonwrepreaenunives of this city to enur upon the V Q above-mentimid Property for inspection pmp i ;a. E. (We)agree to sive,indemnify sed keep harmless the City of Cupertino..moat U liebilitiee,judgm,nu.rose ane upensn which may in any wayacmu.,wro,said City } W in consequence of the granting of this permit. ' F. P. APPLICANT UNDE RrANDS AND WILL COMPLY WITH ALL NON POINT gOD CE BE A'fIONS. n , U igna., l APplwailCon nor Date CG HAZARDOUS MATERIALS DISCLOSURE^ Will thc applicant Or future building occupentnore mm-de hound...mare nal Re-roofs ro defined by the Cupertino Municipal Colic.Ch.pler 9.12,and the Berlin and Safety Code,Section 2533241' Type of Roof ❑Yes (3 No Will the applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being emit havrdios air canumimnu as defined by the Bay Ana Air Quality Management installed. If a roof is Installed without first obtaining an inspection Y<s ❑No I agree to remove all new materials for inspection. Applicant I have land the navtdaa,marenaH rcquiremenu ander Clasper 695 of the Call- understands and will comply with all non point source regulations. forms HuIN d Safety Code,Sccuom 735115.25533 end 25534.1 uMormad than if tie building does rep currently have airn..1.Nm it is my responsibility to sonify the occupant of the try. menuwhi�rep f tpnw tc isnueeceofe Cenilicee of 4cupeney. /W. Signature of Applicant Date ner reuthonzed."m Date All roof coverings to be Class`B"or better OFFICE