05010157 CITY OF CUPERTINO � ,Z 77-117
BUILDING DIV ISION PERMIT �CUNTR ,CTbR IN 'UIiMA'TIUN
BUILDING ADDRESS: _ ALCO CONSTRUCTION PERMIT"(05010157
ER'S NAME: PERMIT L5UH DATE
PHONE: SANITARY NO. CONTROL NO.
1 .INFO
ARCHITECDENGINEER: BUILDING PERMIT MS
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�10o LICENSED CONTRACTOR'S DECLARATION lob Description
p+j 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
w Lh Smdun70 )ofDivision3af Cc Buri aVWPrrfeWuas Cab,"re licaeseb
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miceose lsas=c—, ad elect 3QL TI-ADD HOOD/MODIFY ELECT/GAS�,b LCucumber
Irg- Dau � � Conuacmr
ARCH CIB DECLARATION
B i underawd my Plant shall be used as public recmdt
ted Licensed Professional
5P OWNER-BUILDER DECLARATION
i y I herthy affirm that 1 am exompt from the Convectors License law for the
02 fallowing mason.(Section 703 1.5,Business and Pmfamons Cole:Amy city or aunty
$ which requires a permit to construct alter,improw,demolish,or repair ay structure
prim in its issuance,aha requires the applicant forsuch Permit to File a signed suument rnnn
�< thathculicensedpursumltotheprovisionsoftheCommon'Wcenselaw(Chapur9 Sq.Ft. Floor Area Valuation
(canmencing with Section 7000)of Division 0 of the Business and Professions Come)or
.. Nat he Is matters therefrom and the basis for the alleged exemption.Any vloladon of
Section 70713 by any applicant(m a permit subjects the applicant we civil penalty of ane 3 Gt'�b[91OI�e10 0 Occas
not mom Nan Bw hundred dollars($500). Occupancy Type
0 1,as owner ofthe property,ter my employee with wages as tkbsole ampensmi
will do the work and the slroctum is notlatended orortered forsale(Sen.7044,Business
and Prolicsi Code:The Contractor,License Law does mum apply to an ower of Required Inspections
property who bas llds ter improves themon,and who doci work himself or through his
own employee.Provided that such improw meow ootlnueded aroQesed fmsala IL
however,the building or improwment is sold within one yea of completion,Ne owner-
builder will base de burden of proving that he did not Wild or Improve for purpose of
CON).
❑1,as wi of the property.me ndasively conuaning with licensed aniramoer to
come,La the but (Sec.in an owner
of and property
who
Cade:)The es summer. ndi
come law doe trot apply m is was of property lice Gilds or impose Centro,and, V
who se La b for such projecu with aeomracmKs)licensed pursuant m the ConlrsemM1 .
License law.
❑1 am exempt under Sea ,B At P C for this maven
Data
WORKER'SCOMPENSATIONDECLSRATION - - - '
I hereby affirm under mostly of perjury one of the following declandoom
❑I W w sed will mainuin a CWFicau afConsent toself-Insure fm WarkmYCmnpen-
mums,as provided for by Section 7700 of the labor Code,for the performance of the
work for which this permit is issued.
❑1 haw and will maintain Worker's Compensation Iosersna,as required by Section
7700 of the labor Code,for the performance of the work for which this pcmtit is issued.
My Workers Compensation Insurance carrier and Policy member art: �(�/
Carrier. ' f ff'� / WC> Polity Nm.:J, 21.Z- / SOY
CERTIFICATE OF EKEMP LON FROM WORKERS'
COMPENSATION INSURANCE
(Thu eectia need mot becomPlemd If rise pemth life,.headed dall.($10(1)
or las.)
1 certify that in tite performance of the work For which this pcmtit is issued,I shall not
employ any person in any n inner an as to become subject to the Worked Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.arm,making this Certificate of Samaritan.you should
become subject to the Worker's Cmnpeosatiun previsions or the Labor Code,you must
,J O forthwith comply with such Provisions m Cu Permit 0111 be deemed mwked.
z y CONSTRUCTION LENDING AGENCY
f~ I hemby alnrm that then is a construction lending agency for the performance of
lYi ? the work fur which this permit Is issued(Sen.3(1 Civ.C.)
W 0 Lenders Name
7 z IandersAddmas
V Q 1 minify that I hive mad this application and sou Ca the&bow information is
W!'. correct,1 qra to amply with all city and county aNlnumes and state Irv"relating to
0 building convection,and hereby authorime reptesentalhes of this city to enter upon the
W above-modmi property for Inspection purposes
G (We)agree m sew,indemnify and keep harmless the City of Cupertino against
y Iiabllities,Judgmenu,cosm and expenses which may In any soy acerae against said City
fJ 7 in consequence of the granting of this pemtit.
rte- APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
-
SOygCE RaGULATION
�/L ✓u -3/6/,9S Re-roofs
sirlutme arnpPnc ZaARRDDOOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applicant or future building atcupent mom or handle hamdous material
as d0ned by the Cupertino Municipal Cade,Chapter 9.13,and the Health and Safety
Section 35552()? All roofs shall be inspected prior to any roofing material being installed.
C]Yes ON.
Will the applicant or future building occupant use equipment or fkvias which If a roof is installed without first obtaining an inspection,I agree to remove
emit haeardoa air conterminous as dcEncd by Ce Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yeas
I haw mal the huardous materials m ldicre nb under Chapter 6.95 ofthe Califor.
.is Health B Safety Cab,Savmu 25505.35577 and 25334.1 undersund On if be Wilding
data not cumentiy haw a mount,Ont It is my responsibility to entity the occupant of the
mquire nuwhich most,be.met /'ormhimmuceoracmin,`of apamy. Signature of Applicant Date
ryl� l-!/Z6 , All roof coverings to be Class"B"or better
Owner or authomud agent a Dam