00030121 OF
CITY
DIVISION CONTRACTOR INFORMATION: PERM TNo.
PERMIT rUQ � �01 2
BUILDING ADDRESS:
;=�� ) c� SANITARY NO. APPLICATIONSUBMITTALDAT
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. .SNA a o?-3 90 / fell/ IYV�
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ARCH] BULDING PERMIT INFO
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F G LICENSED CONTRACT'OR'S DECLARATION
o i=o I hereby afro Nat i on licesued undes provisions of Charm 9(..Mg ,I Job Description
P ytw wiNSation]000)of Division3of Ne Busiross and Protessiom Cad,and myhomseis TC9
in bill
LR nfull force end e
y 6 ae Class Lic,g I v (jA )
F
0 Dam Convenor {� ,S
a O As that W T'Suse DECWtATON
LL < denland my plans shill W used un public records
C.u o Licensed Professional
OWNER-BUILDER DECLARATION
I_Z i I hereby aRirm that 1 am exempt tram the Convector's License Law for the !/ 9✓9 Z N
wZ C following=am(Section 70313.Busixas and Professions Cuda:Any city Or county W
C wltims regaun is p rmn In,wormer.ell«,improve.demoliN,or repair any svunurttJ
Mar toits nauance,ilsoreal(the appli far each Formal to file aeignedautemcm Sq.
/Ft. Floor Area /`Valuation to/
Nm
at he is licensed puranl to the provisions of the Contractors License,law(Chapter9 l'" O < ,J C)
(coswtmncin,with Swum 7")of Division 3 fthc Business al Professissm C9d)w APN Number Occupancy T e
that he is caempt therefrom and Ne bunts for No alleged rxcmption.Any violation of // P Y YP
Sector,7031.5 by any applicant rap a pemth subjects dsc applicant to a Civil pnulry of Z—l� O
not more Nen five hundred dollen(5500).
O 1.as.,of Neproperty.w my employ«s with wagers as throinlec ,.do., Req Ulrefj Inspections
will Bothe work,andthe machine is not imcMlwoReted four unle(Sec.10M,Business
and Pofeniom Cod:The Co imucho s License law daps not apply tom owner a
property as,
Wilds or improves Nerenn,and who docs each weak himself w though
his own employees,provided this,such improvemems sure not intended or oIercl for
We.If,however,the Wilding or improvement Is sold within one year of wnmluion,the
owner-bullde,will has.the Wlen of moving that he did and Wild or improve tar parr-
pose or sole.).
constI,uownsof Nepes.70, as^ sinessiv ad confession,with:)The Aonnownoni-
Li-
move
La Ne project apply
.an Business and profession,Wa Code)The Comsamb and
cense law Cases not empty m to owns of rectory ace Wd p of im to theCncon,sod
whoconnecla fm each proJau with ecanvadw(H licensed possum to the Contractor's
LOwase
❑I am<xempr under Sa. .B R P C for Nis rcaaan .r
Owner Data
WORKER nder p COMPENSATION DECLARATION
1 handy iRrm under pvW ry of nice.o^e of the followingworkesiccr
❑lhave mWwillmasbi Swum
of the LabrCode,forthe Workeh Compete � QW
cation,as provided fw rs S«ton 3100 of the tabor Code,for the performance of the
is Is have
which this maintain
is oCllw
1 have end will o des to ine a Compensation Insurance,u required by Section
My
War Wr Cad,to Ne m ofdmwort for which Nis permit is tarot.
Ca Wor prnsei fr,aer 'o and Poliryy, pct Z31,1—
Cuder IiNo
CERTBTC OF EXEMPTION
FROM WORKERS'
COMPENSATION INSURANCE
(This aatinn need and becamplemd Jthe permit is froom harmed dollen ISI00)
or level
I oyWiry that
per in the performance meadows n as t work for which this the parent is wl'Coawl.I shill
not employ any Canon in any men«r o es m biome aubjat no the wahcn'Compcn-
Applic awsaf California.Date
AOnC t
NOTICE.b APPLICANT:If,cher milting this Certificate of Excursion, ,y should
M1ecame subject m the Wwkcr's Compensation provisions or Ne labor Cod,you most
fonhwiN amply with such provisions or this permit shall W deemed rooked. '
CONSTRUCTION LENDING AGENCY
0 I hereby affirm Nat there is aconstmetion lending agency forthe pennmunce a
Z 2 the work for which this permit is issued(Sec.3097.Civ,C.)
PC4 Undoes Name
C4 } Lenders Address
W E 1 unify that 1 have rod this applicant.and ame Nat the above numeration is
Gsat end 1.,.to comply with ell city county man anca and Huta laws alining 1.Z) Z. building earoadwon,and hereby autlnnu ameaenwlves of this city reenter upon Use
U Q eWvumentioncd propmy for inspection purposes.
is. Fw (We)a,ra m save,indemnify and kap harmless the City of Cupertino against
Q U liabilities,udgorems,c«uend C.M.which may in my way accuse against said City
} Ltl in consequence of the Booting of Ws proud.
rFn APPLICANT UNDERSTANDS ANI WI LI.COMPLY W I'flt AIA,NONd'OIN'T
U Z SOORCP. LATI
2� I a / P-& 10
Sigtut al'Applicen amactw Dam / if/Il'
N RDOUS MATERIALS DISCLOSURE /P
Will the applicant or future building occupant store in handle hazel...material O
as defined by the Cupertino Municipal Cod.Chapur 9.12,end the Bedth sal Safety
Code,Section 255324)? �� Type of Roof
❑Y0y. gbh/'
All roofs Shall be inspected prior to any roofing material being
Will Ne air cinnt or future Wilding by the B use m Air em or devices which f
emit huudaus an conumitunu as deflted by the Bay Aro Am QtWiry Mmagemrnt installed. If a roof is installed without cast obtaining an inspection
Diane'? I agree to remove all new materials for inspection. Applicant
❑Yes
I have rel the hazardous materials mr,inmenu under Chapter 695 of the Cali- understandsand will comply with all non point source regulations.
t' fano Resbt A Safety Code.Secaom 15505.]5533 and 2553x.1 understand that if she
Wilding d«andw my ,,,.tenant,Nat it is rtspanaibiliryomify the occupant (��Iy/7�_liRr//�`^ ✓ S/
ofthr uwh hmav at tpnww is my
Cdlo)inte fOccu y
� y Signature Applicant Dale
Ownc ore gemData
All roof coverings to be Class"B"or better
OFFICE