00020151 .. CITY OF CUPERTINO PERMrrNO,
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION:
it BUILDINGADDRESS: �� , VV —V�.=� •+
R ggQ]f N SANITARY NO. APPLICATION SUBMITTAL DATE
�t ,. y' � y. �i��. ,
OWNER'S AME: 4eo -�+SM
f�jLIC' r c //�� //// /� ♦. - N/C ,CONTROL#
ARCHI'fECT/[NCINEER - _ BULDING PERMIT INFO•
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>HOy- '+ LICENSED CONTRACTOR S DECLARATION. o, /
O z—❑ 1 hereby aRem tlw l un hcrnaed undo pmsivons of Chapin 9(rommemng• "Job'Description
rotty with Seca used of Divnsmn3afdre Bua sand Profeniov Code aM 1.is //�� � ( -
��a in full force rode c f/Ys//L/ / CA'—,
O W U License a LIc
a°' Date - Convm .�
O _ ARCHITECPS DECLARATION +
S a • 1 undenuM.,,[.a shall be uxd as public mmrds
rri2g S O Licensed ProfceslmW -
S=m OWNER-BUILDER DECLARATION
t_ a - 1 hereby affirm that 1 am exempt from Ne Comracrors License Law for the • ' - ',
s€❑ following miss .(Section 7031.5,Business arta Professions Code:Any city or county
.;Rwhich requires a permit m comtruch v r.improve.demolish,or repo,any strumae - ,
3_ S - Ft. Floor Area Valuation -
prlmminiseosna.dmrc9uimssheapplicantfmmchpemdtmt. .Law(Chaptem fl'
thntheinisig wait partners Sm.mthe pmvisioenof Ne Contractors Licensearim(Chapter p , -
ImmmmangwhthSecdon)nandarDivisi nee efineljlis.aandon:A.,omcmm« -) so umber Occupancy Type
WI he is campy anrtfrom and da Wsis far the alleged exemption.Any violation of 7��3 1]I ,svv P Y YP
Section 7031.5 by any ded doll rs a permit wbjms the applicmno a civil penalty of �'CJ Cl .i•
m mom than ave hundred dollars(5300).
❑1,as owner of the propeny,ormy employees wird wegesu theiraole rompenution, Required Inspections
will Bothe work,aM thesmucare is not lmeededoroBcred fmsalc(See 7044,Boom. y. '
end Professions Cade:The Ci neon's Lt...Law does red apply m an owner of
property who bullda m impms.thereon,and who does such work himself m duough
his own employees,provided that such improvements am nm inkMed or offered Re
We.IL hawevmo the building or imprm'enwnl is sold withinone yearn(completion,the t _ - ,
+ owner Wilder will have the burden of proving that he did not Wild m improve for For. •` /
couofselothesr.). ". i
1,ae of the property,am exclusively contracting wish licensod cmonscton to
came a d project apply
7W.stoi Businc l sed rt,who
Ceded The Comrsum,nd '" 4
corse law dace not apply m ts owner of propmy wce sends or improves thereon,and•
whence contracts Be such projects wird a conlnnorfp licensed punuanno the Conbum/s
D
License Law. r --, l
❑lam exemp undcrSec; ,BRPCfor Nis ream
Owner l Dace f _. r
WORKERS COMPENSATION DECLARATION
1 hire by affirm under penally of pepuD one of the fallow g de f t _
�❑Ihave and will maimatn a Ceruicate of Consem so self-imme fo Worlims Compen� '
&mio,aspmviBMfmbySufion37MofNcLaborCWe,forth perfomunc`of she.
..it for 10 h this permit is'ssucd
'❑1 have and will meinwn Wisdom.cmuri neuron Imureme:as rtyuirM by Section r
3700of she LeborCode,far the performo"¢e of the work for which Shia permit is issued.
My WorkeryCoe/pc Secy' �Iy,gree carric ax d Policy numNrare.waSaQ��
Cnriee /��fCarrt/!•N of NOS_Policy No.: //''VVJJ 9977((00 r '
CERTIFICATE OF EXEMPTION FROM WORKERS" - n COMPENSATION INSURANCEor lass.)
" (This:mcyim neednmWcomplead if Ne pemtlt is(Drone huMrW dollen($100) n
I certify that in theperformanceaf Ne wmk for which this permit is issued,I shall, -
not employ any Parton in any mmmr w m m become subject m Ne Wuhan'Compere- - - '. r' - _ •• -
sationLaws ofCalifomia.Dow, + '
Applicant "I - - - •. ' ..
NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you should -
become subject to the Woeker's Compensation provisions of the Labor Code,you mum -
fanhwith comply with such provniona or this permit am)W deemed revoked, s -
CONSTRUCTION LENDING AGENCY s '
Q I hereby affirm shat them is a commimi a lending ,an,forsheperfnm ir" + ,
Ne work for which this permit is issued Sm.3097,Civ,C.) - • ,
t.. lands.Name Is
�i 7- Lander,Adder. - - -
W 0 1 mify thin i have read this application and sum that the above infnmamin is
VO, camsm:I super,m comply wish all city and county oedinames and sure laws relsfing to +
buildingconawcuon,and herx6y malumse npecsenutives ofihia coy to nnerupon the 1.
abovcm tioned Mm y fm inspection puryo
W FyI I I (We)agree to save,indemnify and keep harmless ted City of Coperlino again •'
+'� O harbilities,judgmena,cru and expenses which may in my way amme agAmuaid City +
�., Wrn consequmce of the gemting of this permit' _
APP1.ICAN1UNDERSH'ANUS ANIS WILL,COMPLY WITH ALL NONa PINT „
'U y SOURC REGUTAf10 _.
�,/�,.
Sigvmre of A,Iic.n on..c,., - Dam ,
HAZARDOUS MATERIALS DISCLOSURE'
Wilby t epplicmt or future Municipal
Cu oroupmt atcreoeaid s e Heap and Safety Re-roofs
al defined im the Cupertino Municipal Cade,CWpmr 9.12,aid she Hee1N and Safety
cedes«tion uvz(.d7' Type of Roof
.❑yea t9'if •' ' .+ ' '
W„the:ppfieantaefameWRdiate«mo,,a;e 9n;pmn,aeav;e,wh;eh All roofs shall be inspected prior to any roofing material being
S r tothawdousairconnminmua.defrnedbytheBryAreaAirQualityManag$meal installed, If a roof is installed without first obtaining an inspection
(]Yes AlNa 1 agree to remove all new materials for inspection. Applicant IMI.send she IntonationsIntonationsate
ons materials neuirements ander Chapter 6.95 of the Cali. understands, and will'comply'with all non point source regulations.
.(amu Health St Safety Code,Sections 25505,25333 and 25534.1 undersand thin if the -
W ilding docs n r cunmdy eve a uront.dm it is my octsea sibility m nai(y She mxupmt
,
ofthe��fIaL- m
mes h¢h�st�W prim m issuance of a Certificate of Occupancy.
owmTdr kathon:ea ag;m - •� `?L-�aa Signature of Applicant r - ;Date .
- All roof coverings to be Class"B".or better
OFFICE.' . , ;.