00050073 CITY OF CUPERTINO PERMrr NO.
BUILDING DIVISION PERMIT CONT 'INFQR'MATI 0
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0SD6 �3
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BUILDINGADDRESS: '11
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A IiCOENGINF.ER f BULUING 1'ERMI"f INFO -
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a' v LICENSED CONTRACTOR'S DECLARATION
Z "= Ihereby alfa.ural I sm licensed under provisions of Chapter 9(commencing Job Desgiption -1� n
uwith Section 7000)onNsision 3 of Busincae ud Profmiom Code.and my liana.is N^O v` '-¢ /.�!Kq A'ca., , ,. - ` ser , �' „s nPn_._w�eK_O
z z a m mu force andert m. 2)-L3 —9 q I t/iJ�AI�!{VA ,vvv""""'„`CCC T
nO w U Liccnu Class I I Lic.N I I �
)uS 3 Dam S ARCHn`ECI'S DEC AI'I K,/�(,t�l.�.CN..� 'li'1 a�/`�"'a�`u'� Nz CI
fO I
N I udentend my plans shall bo used as publ /I ,/ii ICY NyL(,(j,Y �Q
on
d C o (/,.a^^u1/ fi.��-fac.u.ee i('-�l,(1✓V l.vlAN(JCy `
e.
Licrnsd Rofeenlonel
OWNER-BUILDER from
DECLARATION
1 Wrtby affiect that 1 am exempt from Ne feanlmmfs License taw run the 4•Nki1.1/f`�J-fC!
S D following eons..(Section 1031.5, .9N. dc
a and Prof"alone Curie:Any city a county
3 a which requires a permitwctm,alter,permit m comimprove, moliN,m rtpah any a... Sq. FL Floor Area Valuation
prim to its issuance,ds mgvims ale applicant formth permit to file a sigKd atatemem p
that he is licensed pursuant to Ne provisions of the Contractors License taw(Chapter 9 V
(oro ncingwiNSatian9000)ofDivision3oftheBuaixasdl'rofmimoCode) APN Nb r Occupancy Type
that he is exempt therefrom and Ne basis far the alleged exemption.Any yiulatb n of 3 l 2 1um�^
Section 7031.5 by any eppticaut for a pemth subjects tbe applicant 1 oval born of G
not mere Nan five hudned dollars($500).
O1.as owner of lW property,m my employees,with wag""then side counters I nspectl
will do the work.and tW hmu,me is tet Intended m.fleted for sm,(Sec.7014.Humors
and Prefcumu Calc:The Cmuractoi s Lt...law dao m apply to en owner a
property who builds or improv"d ertor,and who dao such soh hiamalf m through'
his own employees,provided dw such improvemema art taut ineded or offered for
sde,If. owes
”
.the building or improv mem is sold within m,year.f compleuan,the
own-builder will have the burden of proving that he did not Wild or impose for pm-
pme of we.).
1,u owner of the property,am eacluaively contruung with licemd c.mncton to /
construct the project(See.7061.Bmincss and Profcadom Code:)The Convvctm's V-
In.0 law dons.,apply,.an...,of property.1W Wilds to into'"tWrem,and
whoconuacts for such prolan with.conuacbms)Iicmand punuenuu the Contractors
License
e son"runt under See. .B&P C for this rtaan
wner Dan
WORKER'S COMPENSATION DECLARATION
1 hereby aRIW under penalty of perjury one of de following decimations:
I hive ad will mainuin a Cenifican or Comma m erif.m um fm WorkervCompen-
wion.as provided for by Section 3700 of the Labor Cedn,for the pio untonce of the
work for which Nis permit is issued.
1 hive and will mmmd.Wnhers Compensation Insurmce."rtgdrtd by Section
3700of the labor Code.for the peff—c of the work for which this permit is issued.
My Wrter
kiLmnp�e tion 1 pynee and Polity npm�eyes a.�q
Carrier �e-"a' AA �' fJ Policy No.: f S
CERTIFICAn OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This nation and trot be completed if the permit is fm one hundred dollars(SIM)
m lea.)
I certify dust in the purfomnnce of the work for which this permit is issued.I shall
ori emplry my pJbn in any bon.as x11.boc.me wbj.l to the Woken'Compen-
troh n Laws or California.Dan
Applicant
NONCE TO APPLICANT:IL def making this Cer ificau of Exemption,you shwM
MLOTe FdljdM1 to the Workers C.mpemsatlon famismo.s Of NC tabor Code,you It
const comply with Inch provisions or Nix Remit Nall be domed nvokd.
CONSTRUCTION LENDING AGENCY
Q p I hereby affirm dna thcte is a construction lending agency for de performance of
the work for which this permit is issued(Sno.3097,Civ.C.) _
Lenders Name
Ceders Address
raaj ? I certify Nam I hove reed this application end moa that Ne above information is
L calaim o cmply withcoy med courtly otCvnces and cue laws relating to
U uildmileosverty Wmby.mhmiurtpeunntivea oflhis city to mnrupom e
U 0 abvatamionod property
fm i rmity an puryaaea.
ts. U (We)ague t.vent indemnify end keep .,ibandanas the City of mCupnino against
17 U to .nonyomg of
ateand expenxs which mryin any way accmeegdnst said City
} L.7 in consequetce of tW gg of this permit,
F-i
91e AI'PLICANI'UNDf:RS7ANS1ANUS AND W'ILLCOMI'LY WITH ALL NON POINT
FUn Z IRCFREUULATIONS.
igndurt of Apphernl/Contmmor Dan
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or fumm Wilding rccupenl store or handle hasudous marerial Re-roofs
as defined by the Cupertino Municipal Cdc,Chapter 9.12.and the HedN And Safety Type of Roof
Cale.Section 255321x)? yP
❑Yes ❑No
Will the applicant or future building mcupent use equipnem or A"iccs which All roofs shall be inspected prior to any roofing, material being
herallou air conlnmimenn as deFlnd by the Bay Arca An Quality Memgament installed. If a roof is installed without first obtaining an inspection
nom" I a free to remove all new materials for inspection. Applicant
mor ❑rex ❑No
I have "d eh.s d.Ya manrid.rt9Yire enc under Chapter 6,95 oldie Cad. understands and will comply with all non point source regulations.
u x"IN&Safety code.Secuona 25Yd5,11531 and 11534.1 understand Nat if the
Wilding dons red cun"dy have a it...Nat it is my responsibility to Way the content
of 1W rtquumadur,which must be mel prim m iaauance of a Certificate M Occupancy
Signature of Applicant Date
1Tvncr or euthorizd n
agent Da
All roof coverings to be Class"B"or better
OFFICE