00030120 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:,
BUILDING ADDRESS: n D
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ARCHI'117CF/ENGINEER Ci PERMIT INFO
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F y i LICENSED CONTRACTOR'S DECLARATION
O I hereby aRrm Nu 1 em licensed under provisions of chapter 9(commeneing / Job Description
rw,_m with Seation7000)of DivW..3of the Bwnd Pm
uainnaofnsioCode.and my liana is
x l In full
o
o w u Oete connector ,r /� /J yrs
LL O g I undemuind mY PIenRSIWII Uwe aced eaEPubl'c�remN.a �y�.�P
TIOV
��a add -S� S3�7- ` VV
to a n License Pro(cuiorul �NX� ^-per~ Y
u)S_
OWNER-BUILDER DECLARATION
x 1 bcreby aRnn stat 1 am comp from Ne Cenec
trtors License Lew fm de 1 s P
gal F 0 follewina
g asom(Section 703 L5,Business and Profession.Cim cou
Cie:Any city nty Lf' V JJJ
w3$ which requires a permit in convect,ester,improve,demolish,or repair my structure Sq. FL Floor Area Valuation
prim to its issuance.also requires the applicmt for such permit to file•signed aYtemem / / �r /�
Nat he is licensed pursuant to Ne proean
visions of Me Conafe Berra law(Chapter 9 _J
(cm.neemng with S,wm7W)efDiaieion3ofMeBo,irwn itprofusion.Code)ce
nOccupancy Type
that he is eacp meteo-om and he India for he allege arra ilirm AY vi-Imm of APNNumber
;4
Section 7031.3 by any Wbcam for a permit subjects rte applicant to•civil Family of 3 4 -Z— - 13 — 03
net more then five hundred dollars($500).
I.mowntrerthego'rty,army.mploY«.withw.gauthalrwleaem'mem. ARequiInspections
will do Ne work,and the structure is rot intended or offered for saw s (Sec.7M.,.,Buaine
and Profession Code:The Connector',License Law dw,rwt apply to an mvner d
property who builds or impmvcs Mansur,and who does such week himself or through
his own employees,provided that such improvements are me intended mowwd for
We.If,however.de Wilding or improv.manr is and within ere y..fcom Ic6m,the
owner-builde"will have the When of proving Chet he did not build or improve fee qts.
'se of sale.).
h do over of alta pmpen%am eaclueivelr convening wish licenced combectors to ( O
empuract Ne project(Sec.71314,Buri.and Pufessimu Code:)The Centranoi s V- 40
cense Low does not apply m an owner of property who Wilds or improve thereon,and V
who contracts for such pmjmu with a convectors)licensed punuanuo the Convectors
license law.
C)1 am e.cmpt.ndcr Sa. .B Q P C for this meson
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under family of perjury one of Ne following declantiwu:
]I have andwill maintain itCenificareofConsen0o self-insurefm Worke'.compn-
ushon.as rovidd fm by Section 37M of Ne Labor Cale,for the grfmmaw of the
k for whist Nis permit is issue.
I have and will maintain Workers Compensation Insurance,as required by Section
700of she laborCde,far/ppllRpe anceof thcwork forwh'hthi,permitisieamd.
a I, CantRnser icy No YPnmb4 .ice-7��f/� D
CERTIFICATE OF E%EMPfION FROM WORKERS' -
COMPENSATION INSURANCE
(Thi,section nes nor wcompllm difthe sermon.anent hundred dollen 13100)
or leas.)
I certify Man in We performence of the work for which this permil is issue,l shill
rot employ my pawn in my mount,an as m lawma,ed,,se.to the Wmkcn'Cmnpen-
satien laws of Califomia.Dam '
Applicant
NOTICE TO APPLICANT:If,after making this Canificev of Eaemptim,Y.should
become wbject m Ne Workers Compensation provisions of the labor Cde,you must
forthwith comply with such provisions or this pamitshelf W damcd revoke.
CONSTRUCTION LENDING AGENCY
Q O I berzby Wrm the there is a continuation lending.prey for the perfamunce of
mZ the work for which this permit is issued(Sec.3097,Civ C.)
EeLenders Name
Ra > leder,Addrt.a
W 1 c<rd(y,het I have read this application and suite that the above information is
A. .omen s agrec to comply with of city and county odirmurs and cum laws rearing to
V O
Wilding constrad..,and herby ebo
adra tepiv
reacnwes of Nis city m ame'upe
on B
above-m.miewed pepsin for Inspection puryoa<s.
sect (✓ (We)agree to save,indemnify and keep harmless the City of Coition against
Q f..) liebilitiea,jdgmcnts.co,ts and eapnses which may in my way acerin wout slid City
} R7 in consequence of the granting of this'nmol.
I4 APPLICANT UNDERSTA NDS AND WILL COMPLY W'I'TH ALL NON-INA NT
SOURCI�'?/fR}�jLBll�
Signature of Appltcan o rnictm U,tT—
RDOUS MATERIALS DISCLOSURE.
will she awicam or future Wilding receptor store am
hNasa
e hder.maurial - fs
in defired by the Control Mmici'1 Cod..Chapter 9.12,and the Health and"sty Type Of ROOF
Cale.Section 2.1532(.17 YP
❑Yea ❑D"'
Will sh<a'Iicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being.
cm,huadou,air contaminants as defend by the Bay Arca Ah Quality Mmegcmenr installed. If a roof is installed without first obtaining an inspection
District? (�Nn I agree to remove all new materials for inspection. Applicant
❑Yes
Ihave read td huudous mNterlal]rryuiremenv oder
Chaffer 6.95 efthe Carl-
of
under $ will el) ply with all non point source regulations.
forrda Health k Safny Code.Sectiau 25505,25633 and 2553..1 understand that if the
Wilding na currtntlyhav.eunanLthatitismyrespmsibiliry mnaiIyyy the oc t 20 oQ
of she a hieb most be r prim to I..u.nee of a Ced 11 nbbC up y.
owneror,mhodz ,//��Gll Signature of Ap icant Date
All roof coverings to be Class`B"or better
OFFICE