00030119 CITY OF CUPERTINO PERMITN .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING.QDDRE54:
^���O ,',//,V,/LJ, {/2 ''_- /f//���� �� ,t(/t y//�1 SANITARY NO. AI'PLICATI SUBMITTAL DATE
g/1� 'NAME' � _ A � J,390 � ,l/`^""a'sry✓-`iW ( L.
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IICHITEC'1'/ENGINEER 9ULDING PERMITINPO
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LICENSED CONTRACTOR'S DECLARATION
°vi- 1 hereby affirm thrt I am licensed under provisions of Chapter 9(commerning Job Description
T/L
1-So with Saxon)000)ofDoision 3 of Ne Business"professions Code.Wmyliccrue is
=YSSJ in(YII(Orce dC
re0 i V License Clas �
tc 3u Date CgDE ^
=O g ARCHITECL'S DECLARATION 1 Il.- \L� J 3 Z7—I S �-✓s sus - .
f 1 understand my pians mall be used u public records (,L(�, V
° Licensed Profe.slonal QM.e� �G' Y✓t I
u^_ OWNER-BURI.a
DER DECRATION
i hereby affirm drat 1 u.exempt from the Coao-acwrt License Law for the /J L
+� D following feswn(Scaimi INGI.S.Business and Plofersiona Curie:Any city or county Z
Vr (J G f'
whim mquiree a permit on construct,alter,improve.demnrsh.or repai any suuctme Sq. FI. Floor Area Valuation
precious iasuea..also requires the applicam for rush permit to Fit.silosd.ba.t
Net he is licensed pursuantNG7O0.
Ne provisions of Ne Contractors Lianw Law 15 o/5 - o-7)
(commencing with Section 7Wm of Division 3 ofthe Business end Professions Code)or Occu
tlut he is camp therefrom and the buffs for the alleged exemption.Any violation of Aq PN lbeNumber, Ptine y�'Pe
Section 9031.5 by any applicant fora porsk subjects the applicant ...ivil ponedry of ✓< < _
rM more titan five hundred dollars(SSW).
❑I,uownao(Nepropeny.mmyempinycerwiNwage con irwiccompcna+tion. Required Inspections
will Studio wosk,and theawmure is not uncoated communed!fortele(Sec,7W,Business J
W Professions Code:no Contractor's License law doss not apply ro an owner of y
emptor who bunds or improves frame,W who door such writ himself or through
his own employees,provided that such improvements are not intended or offered for
We.If,howeter,the Wilding or improvement is Sold within one year of completion,do, ` I(
Cor-Wilder will have thc burden of proving that W did not Wild or improve for pur- 1
te rF tele,.
or I,u rwm of the Seu.7portent,.tB exclusively contracting with licensed cmetcwmrs ro /
,once U the project ppy ri son w.c,of and Professions Cade:)M Conaenom,and O
cense law deco not apply e ts owner of properly who sued p rr impruvea Centra,end
whence Le-
0
for such pojeco wish asmetmtm(s)Ikerud pursuant to Ce Cunuacmrs t
License Law.
(]1 nm exempt under See. .B&P C for this retires
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby amts coderpenalty of perjury rote of de following declar offers
I have and will maintain acts ificata ofConsertt to self-insure fa Winters Compen-
ution,as provided for by Section 3000 of the LaWr Code.for the performance of the
k for which this permit is issued.
have end will maintain Workers Compensation In ricwc'e,in required by Section
900of Wf Cale,fen cps rttunce ofthe work for which this permit is issued.
My mpetwri nwr dPolky� her qe�11/.I
Conic 'y No:! -m x
CERTIFICATE OF P.KEM[nI N FROM WORKERS'
COMPENSATION INSURANCE
(This xectinn nod nut becompletd ifthe permit is former hundred donee SIM)
or leer.)
I eerily wt in the,perfomsncerfthe..it for whim Ci.perrrut is issued.I shill
nor employ any person In any insurer as as m become subject to the Workers Crosier- .
Saturn Laws of Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you xhwld
So omc subject o the Workers Compensation provisions of Ce labor Code,you moat
Forthwith comply wiC Such provisions m this permit sIW1 he deemed mokod.
CONSTRUCTION LENDING AGENCY
Q Q I hereby am.that there is•construct..lending agency for dies picifin ceof
Z Ne wink for which thia permit is;stud(Ser.3099,Ov,C.)
Lenders Name
0.a > larders Address
Lel 0 1 certify that I have ted this application.4..n Cm the aWvc inf.fim,is
A. corm..l agree to ermad county with all city acounty ordinance and sum laws rh ung to
a Z building construction,and hereby ruthona rtprearuuivea of this city to enter upon the
C.) Q aWvs-remind proprmy for inspection purposes.
Ls. F (We)agree to Save,indemnify and tap hamlet Ce City of Cupenino against
Q V luhiliuo,judgments,case and expenses which may in any way weroe agues Said City
} fs] in consequence of Ce granting of Cin permit.
[� d APPLICANT UNDI:RSI'A NDS AND WILL COMPLY WII'It ALL NON-POINT
V z SOURCIi R y S.
—/z—
Sigtotuic of Applicnnyy n tarot, Date
ftAZARDGUS MATERIALS DISCLOSURE
Will ft applicant or future Wilding tccupml nae of huddle harvdous material - orfs
as definod by the Cupertino Municipal Code.Chapter 9.12,and the HdC and Solely T e of Roof
Code.Section 2s532(ar yP
❑Yes
Will de applicant or future Wilding occupant use cqulpment or devices which All roofs shall be inspected prior to any roofing material being
emit haard.0 air contamilYns as defined by the Bay Area Ah Quality Management installed. If a roof is Installed without first obtaining an inspection
District?
]Yes I a ree to remove all new materials for inspection. Applicant
00 l love red the haucdous maedala ropomons order Chapter 6,95 of the Cali- u❑ erstands and will comply with all non point source regulations.
Toro Health&Safety Cade,Sections 25505.25533 and 25536.1 understand thin if the
huildingdas oil eeemnt.Nar it is mY cespomibilfty If the inI
of the seyuvc s ich st W met w issuance rf a CMnficme of
lb/ Signature f Applicant Date
Owner or euthorudg t r DaT—
All roof coverings to be Class"B"or better
OFFICE