00030118 CITY OF CUPERTINO PERMRNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: -006 3 O ( (. �S
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ARCHITECMENGINF:F.R BULGING PERMIT INFO
o�> 5 293 — 93 v
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LICENSED CONTRACT'OR'S DECLARATION
p 5 1 hereby aRnn that I am licensed under provisions of Chaps« m
9(cnme«ing �gq.5 /A Job Description
s., 'E a
with Section]000)of Division 3oftheBmincas and Rofrniom Cak,ud myliunse is �Q a✓ l✓' ,l////l�f' _ ,per ,,/� //�
p�0zG in full fortnd eaL2 Lic.a //nn r� (.I,f / `/ ✓�^�^
LL 3 r ✓
=Wv�O AS DEC la
I undentasd my Plans shad be used
as paretic rccdds
OW'�
a 6 ficwnd Ro(csaiorW
OWNER-exempt frDEme ConTION ^92-
C Z a I hereby. .affirm(SOU hat 1 em exempt from Ne Conlrnaofs License Law for the T— K Nle J
7=n foliowin8 fmsen.(S«tion 7031 3.Business W Profeaumu Cade:Any city m county '
Ou z. which rtgnirts a permit In com etmm
her.improve•deulim,of any saw
lc Sq. Ft. Floor Area Valuation
prim to its Issuance,also ngdrts Wherein Whe. for such permit in file a signed eminent ac T�
Net he is limmfd purtwnnu the pmvisionsof Ne Cenaactots Cleanse Law(Chapter 9 g/U /J �� (i V
rcemmencingwith S«tinn7Iwo)nfDivision 3oftheBusiness aniI'mraaaiomCods)Or APN Number ecu enc T e
Nat he is exempt therefrom and the basis for Ne alleged eaemptum.Any violation of P Y YP
Section 7031.5 by my applicant fm a pemut subj«a dre applicant to a civil p=romy of 2) 4-2-- 13 -03J,
p1 mart Nan rise hurdrd dollars($500).
I.asnwmrertheprapfnr.mmrempinym.wiNw,geasNeir.mflempensatinn, Required Inspections
and dor.work,ands: ah Can tan,.Lt.. moReredfm apply
1.res comm,
a
and crry em Code:The mines meur i Lianw law does Iwl apply w ir owner h
his own w W build.pr ivided Ru Merton,and who docs such wast Ned m of through
sal own ossa eyees,provided Nal such improv sold w art nal iolendfd d offered for
core If.haver with.building or impf From is at h wilder orf Wild
or
improve her Nf
r-builder will have the When of proving that he db not Wild d inprove fm parr
you of role
h as..of the property.am exclusively contracting with licensed cinnamon to
naw. /
c= Nee
protect apply,.
7DU,Busincu and y vilm Wild,
Code:)The Conaaraca.V- /
cense law does nm apply w s,with
a of pro cords who builds m improve Merton,and A
who .Law.for such proj«x with.<onv«smfa)licensed pursuant w Ne Convectors V /�
Licenu Law. y
1 em exempt under 5«. .B&P C for this lawn
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby Wz m under penalty of perjury one of IIx following declamliom:
I hive,end will malnnin a Cenifcale of Consent to self insum fir Woe ersCompcn-
lion,as provided for by Section 3700 of the Labor Cada,for the pelfemmnce of the
IT which Nis permit hefis issued.
have and will maintun Wua Compemadmin Imunrce.as required by S=ctbn
W ofLobar Cade,fo a inrformasrm of the work for which this permit is issued.
My Wr 1 C n nml ted No J
come °a hfy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(]his sesuar nederut be compifted Have permit is for.hundrfd dollen(S100)
or less)
Ice mytMtinthe perfesm am Ne work for whichthio pemdosiasued,I shill
ntn employ any,Person in any manner an u I.become wbl«t to Ne Wmk[re Compcn-
a10=e lawne(Cali(mnis.Den
Applicant '
We.tub MPW a Wmdx 1f.after malting Ni.rein.rote m Exemption,you should
hfcowit suomp to it Workds Comms Or this provisions of Ne laved cede,you dun
forthwith comply with such provisions m this permit shall he d«med rooked.
CONSTRUCTION LENDING AGENCY
OI hereby affirm thin Nen is a construction lending agency for the performance of
Z Ne work for which this Fannin is issued(S«.M17.Civ.C.)
landre,Name
's Address
fs7 ? land=r1 certify dw I have rad this tlWheri in,and 61.11 that the above information is
M. mend.I agree to comply with all city and county insurance.ard a.laws ralad.g to
;D Z building construction.and hereby aulhorirt repfemnNtives of this city to enter upon the
U O above-menlionnd property for inspection purposes.
(WO.pee to save.Preliminary and keep Nrmleas the City of Cupertino against
U Iiabiliues,judgmeul,ensuand espenam which may in any wry wcmeagain9t said City
} L4 inm.mcmem.of Ne granting of this famil.
E" 9�" APPLICANT UNDIiRSTANDS AND WILL COMPLY WITH ALL NONdroIW
U Z
SOURCE;R/BCULA'rl
Sig.&W Ap,lim nlreclm Da�—
ARDOUS MATERIALS DISCLOSURE
Will do applicant m future Wilding«cupant stmem hardlc hamNous material Ots
as defined by the Cupertino Municipal Code,Chapter 9.12,end the HNth and Safety Type of Roof
Code,Section 25532RO? I / yP
❑Yes ISO
Will Ne applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hersrdous air enatern arms as defind by Ne Bay Arca An Quality Management installed, If a roof is installed without first obtaining an inspection
Disan. I I a ree to remove all new materials for inspection. Applicant
❑Yes
I have real Nm
e lxaddn mmi
araexeinmenn and«Chapter 695 a the Call un erstans d will comply with all non point source regulations.
fermi.Health a Safety Code,Sfmiom 25505,25533 and 25536.I undentand but if the
building elicit dear hev=eanun,that 1,is my responsibility w c
ns ecarper, 3
err Ne, which asst be ren I.tswance of.Canifeueo pe«
� ?d/u Signature of A plicant Date
owner ar authorized ag 1Dam .
I All roof coverings to be Class"B"or better
OFFICE