00030117 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS:
� e �� ' j 9 1�,., C' 00050117
7C/, SANITARY NO. APPLICATION SUBMITTAL DAT
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ARCIIITI?CI'A NGINHER BULDING PERMIT INFO
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LICENSED CONTRA=R'S DECLARATION
O — I hcreb Ron Nan 1 am licensed maker s of Ch err 9(coemnencin Job Description
O N—0 y a provision ap g I/ / p
r!olL� wish Section]000)ofDiviaionJof alio Busimaatd Pofcssiom COde,ae mYlioenx is I U �,(^ -�� L
E in full force W<Re
a a g
On
c 3 Lie.» 7 r yirz, G
LL•s LL y Dale Gmntfeebr % x
5 gI undersand my plea ss slWl�be arced uEpublie mcndds U/)� S3 /15 _ l t
K ��� (VCAAiJ kiE rc a o 0 Wcrnxd Professional
w m m OWNER-BUB.DER DECLARATION
t?a I hereby affirm than I am exempt from Ne Contractors License Law for the L 9 q 2-(Al
as 9 o following mawn.(Section 7031.5,Business old Ptofaans iuCude:Any city a county l
a3 which resistless a permit m cousheacl,alcor,improve,demolish,m repair may su icturc Sq. F���r Area Valuation
— prim to its issuance,also requires the applicant licant forsuchpmest to fele a signed samtemeC
Net he is licensed pursuant to the provisions of the Conmensrs License Law(Chapter 9 , )
(commencing with Section 7")of Division 3ofthe Busineteandl'rolbssimuCda)m APN Number Occ pancyType
Wt he is e.M therefrom and the basis fm the alleged situations.Any.140n of .
Sued.7031.5 by any aanPermit for. subjects the applicant w..wil penelry of 2 —! 3
pmet con Eve hundred dollars 12500).
NaI.a,ewaerarehepwpe=ty.mmyemwgee.wiNw.geA.ANeirwlecomanAetinn. Re fired Inspections
will do Ne work,teak thenwcture is nm imeakodoroReaed for sue(Sec.
7000.Buutvu
and Profeasioata Cade:The Contractor's License law docs not apply to m mvner M
property who Wilda m improves thereon,send who does such work himself m through
his own employees,Provided that such impmvemenu sec not intended or offered for
We.If.however,the building or improvemenl is sold within nate year of completion,the /
owner-Wilder will have the buNee a provieg that he did cot Wild in impassive for par-
pose of sale.).
seasseek
1.he owner of Ne promny,em exclusively contracting wIN lioemed cmvanon to O
oestrum the project(Sec.7040,Business and Profeaime Cade:)The Conaemera W-
cenw law does am apply to m owner of property who bolds or immnvea Norton.aid
who contracts for such projects with a convaclons)licensed puna antro the Ceneumrs
License law.
❑1 em esempt under Sec. .B&P C for Nis reason
Owner Dee
WORKER'S COMPENSATION DECLARATION
. I hemby arm under perully of perjury ole of the following declaatioau:
Cl
I hart and will maivuin aCenificate a(Comrnt m¢If-insum fm Watkcre Orion.as provided for by Section 3700 of the Labor Code,for the peAonnaa¢e of the
work fee which this parmil is iamed.
Marc and will maintain waters Campenaum I.e.as nequircd by Section
ofth nor Code.fn hem err cat of thcworkfor which this permit is issued.
y a, Inpcnar �f nA r c v and Policy`umber Wroo-2- 1
Curicr: CER Policy O rR
CERTIFlC O OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Th Is aasinn need net be compleeed If the peau l iA forms,hundred doll»(S 100)
or less.)
1 certify Nal in the performance of the work for which this mtmit is issued.I shall
nd employ any,person in any^tanner se as a bccamc subject to the WorkersCommry
Which Laws of California.Baa
Applicant
NOTICE TO APPLICANT.If,afar making this Certificate of Exemption,yam should
become aahjtan m the Workers Compensation provisions of this Labor Code,you amt
forthwith comply wide such provisions Or Nis .it shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby al t.the Mete is a construction leading agancy for tee lunfomeence of
Z that work fm which Nis peon t is issued(Sec.3097,Ci¢Q
t..� .N. Lender's Name
Lenders Address
W I certify tout 1 have need Ode application and im ae that de above inf.sion is
�
Z Imam.I agora to comply.0 all city and county mdinaa¢ss and sane laws nelsons to
building croswcdon.and hereby aft aua-on anwiva of this city to enter UPOn the
U O above-namimd property for inspection Purposes.
kr (✓ (We).gree to save,indemnify and keep hamless the Cory of Cupertino against
0 U liabiliues,jakgmenu.emu and eapeves which may in any way aceoeagilnat said City
} Win come9oeme of Ne granting of this pcmdn.
F+. Cl- APPLICANT UNDERS]'ANDS AND WILL CU5IFLY wi If l A 1,1.NON-POI NT
f..) z SOURCI?RFf,A/I��
Sigtumre of Applic i
Dole,
DALARDDkRDOUS MATERIALS DISCLOSURE
Willewecmuni W dng ^Bone od e an mateeRe-NrtrrK
as NEncd by the Cupertino Municipal Cade.Chapter 9.11,and the Health ad
Safety Type of Roof
endo. den 2553200? YP
❑Vaswr-
Will the applicant or future building Occupant uae equipment or devices which All roofs shall be inspected prior to any roofing material being
emil hawdouair r conamivu nat dcfnd by use Bay Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
Insurer? LOtlx/ I agree to remove all new materials for inspection. Applicant
p Yes
I have and the hmadous materials rc9miremmels ender Chapter 695 cols,Cali- understands and will comply with all non point source regulations.
fomite Denim&safety Code,Sections 25".u533 and 25530.1 undmand that if Ne
building doe d cu dy have a I '.Nat it is mY rtsponxibiI."m If Ne occupant
ofthe cry�t6tle awhi hmusebeme or.ouaceofaCdtifc Oec�Gw.
1l 24/du Signature of A pplicant Date
Ownerm.,ulamie agent I Van,
All roof coverings to be Class"B"or better
OFFICE