00030116 CITY BU OF CUDPERTONNO CONTRACTOR INFORMATION: PERMrrvo.
PERMIT 0 0 Q 3 O 1
BuII.Dlrvc nDDREgs: /)
SANI'IANY NO, Al'PLICATIZOd SUBMITTAL DAT
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Ali HITECT/ENGINEER ion) z 93 -93 0 0 BULDING PERMIT INFO
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Hn LICENSED CONIRACTDR'S DECLARATION
i O o:6 1 hereby aArm Flier 1 w licenses order ptvvisions of Chapter 9(commencing Job Description
0_i:in
n with Sation]000)ofDivision3ortheBusinevsard Rvfmnom Cde,WmYliceme is
g��� inraRrmreeudeH 3 Ln.. 7/ 70 )6- 1j- 4 f n
3 o:u""F ' Gm�trrlor y C a t C�end 14ARCHI
ATION
I andcnd my plans"II W used MEpubARA
rsu
a 0 Litmend Profermand CLA
/tel i's'A.n--n !/_JL�a.t' `� ✓^ �/ ��6wsV'Y �.g, 'W�(sIs 1/s+t+Tl
OWNER-BUILDER DECLARATION
r>:+ 1 hereby aRrm that 1 am exempt from Ne Convect-el License Law for the (,I.•L, Y+— 2 Q_ C'f N
S G following remen.(Section?031.5.Business W Professions Code:Any city or mainly V
.1-9 which requim a permit m co.,elms,improve,deneli.h,or repair eery suvcwe Sq. FC Floor Area Valuation
prim m its jim nce,also reclaims the epplicam for each Permit an rile a signed aod—t /S /V' / ,U^Dl
that he is licensed Pursuant m the pros s of the Contractors License Law(Chapter 9 !
(commencing with Second 70DD)of Division 3 ofum Business and Pnoressi ov Cade)or APN Number Occu one T e
dot he is tromp therefrom ad do,basis pie due alkges exemption.Any violation a C� P Y YP
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of �.
not more Nen five hundred dollars(5500).
❑I.aamwnermrthRpmpertr.mmyempayne.withw.gessdRvwktampenratim, Required Inspections
will do the work,ad Ne swcmrt
is not 7(N44.Business
W Proarty whotu Code:The over umo License law thou era words
hi s lf ownergh
of
popery who builds or improves such i arepo who arca such work himself air ehmayh
his awn employeese provides the used improvements ere not intended a offered for
ark.If.however
the building n es of mo int isudd within one year of completion,the
pose o W e') will have UR hosiers of proving that ha did hat Wad or improve fa lav-
pose u s moss /
❑1,u owner of due property,am exclusively comoaung with:)The
cdWmx`ra t.
crate a the pronto(Sec.o an Business ed Property
who builds
Code:)Tha Canvamon.u
amt taw does not applytots owner of popmy who Wilda m improve thareon,and
who convects for such projects with a tonhactmfs)IicenRO pursuant m the Cono-adoJa
Licence taw. (V/
❑leen exempt under Sm. .B&PCfor this won v
Owner D.-
WORKER S
esWORKER'S COMPENSATION DECLARATION
1 hand,alfinn aide penalty of ptijury rote of the following dalamuou:
1haveendwill sold era CenifinteofCon=ttowlf-insumfmWadtatsCompen-
cation,as provided for by Section 3700 of the Lean Code,fm the performance of the
k fee which Nis pemut is issued.
I have and will maintain Wmkei s Compcnutim Insurance,or wired by Smile-
700ofth Wr Cade,f99��ttlh�e performarRe of arc work for which this pemm�is issued.
My Wot i, Co.petwt/dI Or are Policy mhcrpc�11 23 i 7 0
Carrier:»:+.� �ra s boy No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This victim.natant beemmpleresifthe permit is fimm laidrdmllers($10))
or less.)
1 cenify that in the N formanrcofde work for which this penal is issud.I shall
net employ any person in any manner m as to become subject to she Wmkm'Compen-
sation laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Eatm urn,you should
haomc mhjat m Ne Wodrels Compensation pmvi.ions of the Lidb Code.you must
forthwith comply with such provisions or this permit shall W damsel revokes.
CONSTRUCTION LENDING AGENCY
l hereby affirm that there is•emarrecuon lending.9mey forme Parfomwtce a
Z the work for which this permit is issued(Sec.3091.Civ-C)
Immo$Name
�i > Lembee,Address
[YJE I cenify that 1 have read this application and sone that the move information is
L
z mrrat.I agree,m complyd with all city and county ordinances asum laws missing to
U 7 building mostmctam.and herby anlwnu repreunwivn of this city to enur upon the
U C) mbove-mentiones polpeny for inspection lmposes.
4. P: (We).gene in save.indemnify ad kap harmless the City of copies.against J
C U Iiabiliva.judgmcros,cents ad capmvia which may in my wayemmeagaimt said City /J
'w W in consecutive of the granting of this permit. /
i" � APPLICANT UNDERSTWILL
ANDS AND
1H
tCOMPLY WI'' ALI.NON-POINT
V z gOURCI!gF'gillL w `~^—Y—'
3/as u�o
u
Signature of ANO'e ontrtctm Data
AZARDOUS MATERIALS DISCLOSURE
will the apoiicant m future Wi4img rctapso nae or handle hawdous nanmal R /
as defined by the Cupertino Municipal Cdc.Chapter 9.12,and site Health and Safety J
Code,Section 25532(a)? Type of Roof
❑Yea D.K.—
Will the applicant or future Wilding mention use equipment or devices which All roofs shall be inspected prior to anyy roofing r7faterial being
emit haous ale contaminants as defines by On Bay Area An Quality Management installed. If a roof is installed without fi
vNrst obtasning an inspection
Dmm�O YCS I agsee to remove all new materials for inspe5fdon. Applicant
Ihx treed uK hars<dma,metmalm regairemma�dn Claperti.95"fthe Gdi understands and will comply with all non p�.nt source regulations.
Torero Ilulth&Sefely Code.Smuom 255(15,M533 and 25534.1 understand that if the /
Wildingd"csnw ndy have a Room.that it is my mpmnibility mortify the navpad
of the rcono ems x u,must be a prior w ivuaae of a C<ndic f(kc pa
/;"/&L7 Signature Applicant !-)ate'
Owaronuthorizy m Oata r
�.All roof coverings to be Class f 6"or better
OFFICE