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