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00030079 r CITY OF CUPERTINO PERMITNO. BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: © �030V-7 Y BUILDING ADDRESS: n 04 DAT >5 N . TaaTA.r r`Af ANnARY NO A�3!M� C>0 OWnAM[:� PMll..a INC, NIC CONTR La �eAYA� Ht,� -Zb 5-- 3� d�S �A[.�'`�n1'l�L,vt 1� ARCH]'I'ECDEINGINEER V.lv l„"/' V� , - BULDINPERMIIINFO 0 Z- ep-g F, v LICENSED CONTRAC R'S DECLARATION a O-z I hereby aRrm Nat 1 w licensed undo pmvisiom of Chapter 9(wmme«ing Job Description halt aNty wire Sertia'l000)ofDivixion3ofine Busierla WPafessioa Code.WmY license is a W< License rce ChueM eRect. License CLu Lie.g ((( 6 LL N Date Conbaeur F u O ARCHITECTS DECLARATION :^ 1 n enuvdY planil b�uw4a I(C rec«ds spOy ----'OWP[RrBULLDERDECLARATION 1 hereby eRrm mat 1 am exempt from Ne Courtrai License Lew for the i 3 p following moron.(Section 7031.5,Business and Professions Cade:Any city«county iis� which readuisn a permit to comfort.alar,improve,demolish,or reform any Urecte e S Ft. Floor Area Valuation 5 prier to its inumme.also maumes the applicant for such perm m rile a signed suumend �/ _q 750, OQ ON that he is licensed pursuant to e Provisions of the Consumer,U.Low(Chaper 9 V/ (commencing with Section'/ )of Division 3 of0m Bar.load Pnefessioa Coastal car Ap Numb Occupancy Type Nat he is rump do efmm aM the basis for the slegnd exemption.Any violauam of 3, - not i b P Y YP Section 7031.5 by any ap alkant fee a permit Wbj«u the applicant to a civil Foundry of (� pt mom Nen five hundred dollars(55001. I,mowncr ofihe property,or my employees with wage,as mantled. .,.ad". Required Inspections Walde Ore work and dce afocmuis nm intended«oRernd(a We(Sec.]Ou,Busiau —7 � -Z 3 and Pmfelaioa Cade:TM Contractor's Licanae law does are apply to an oweer of l J C C Cyt pepeny w�w Wilda or improve thereon,and who docs much work himself or through his own employers.Provided Nat such improvement art ata increased«oHcnnd for sale.If,however,da building or impmvemem is sold within one yearof completion,the w«obuilder will have Ne burden of proving the M did not Wild or improve for per- 1,not t der Project ct Sm.Ica ,m cadusivdY connecting wire licensed mmeme, i. construct the pmjen(g«.]coat.,Business eras Piofeuiona Codes The Convumla Li. c ulawd«snutappyman were altramony wce Wildsorart W e0outra,eM whocontractsLaw. pmj«n with aconuumrfq licensed punuemmme Conuacwtx License Lew. - ❑1 am czcmps uMcr S«. .B R P C for Nis ruum Ovolver Data �� WORKER'S COMPENSATION DECLARATION 1 hereby,alarm wder penalty of perlury one of the followin8 dee Wationa: / t haw and foie for by eCion 37M of CoamOrCodr,mm fee Worker's Compere 9 1 work r which this for by is Section 3]00 of Ne Labor Codc,fur the perfomu«e of the / k fav which Nis penult is issued. Q, ❑I have and will urn,fon Wortrfs Cance ofthe w rk for we.hi u hquknd by Section O My ofinelabor Code,fo muulator carrier Ors work for which this permitB issued. Ca Worker's Compensation Insurance Gerrie and Policy number aR: Came,: Policy CERTIFICATE OF EXEMPTION FROM WORKERS' - COMPENSATION INSURANCE is (This Witch hand out m Icconpld ifthc permit is f«o«huMrcdddles(5100) ce kin.) I certify mat in the performance of the work for which this Portrait is untied,I sibill Me employ any person in any men m r so as to become subject to the Worker,'Compen- sation laws ofCalifornia.Dau Applicant NMCETO APPLICAM':If,afar,mWdng ria Crnifica a of Exemption,you should become subject w the Watrls Compensation provisions of the Labor Code.you must forthwith comply with such provisions or this permit"I W deemed revoked. COMMUCIION LENDING AGENCY Q O I hereby afro construction em is a coneetion lending,lummy forthe performance of Z mo e wk for which this .it is island(Sec.3097.Civ.C.) C4 LeMc/,Name > Udue.Addmu W1 certify mat 1 have read Nut is application and am,mat Om above inmu foden is 0. ❑ morect.I agree to comply with ell city and county ordinances and since laws miming on Z building construction,and hereby someone representatives of this city to enter upon Ne U ids,eventioned propny for inspection purposes. k. t.. Our)ager to save.indemnify and keep hamdese me City of Cupertino agaiat fJ Rehi110«,jWiff.ma.me spends which may in My way uove againot laid City to Come'uerce of the granting of Nis permit. ti L APPLICANT UNDER' COMPLY WITH ALL NON-POIM' U z SOURCE Rf:GULNI3ONSn he Uconnuwr Dao �� I 7— ATERIALS DISCLOSURE Willtaspptcantor Poore bookimg«cipame«e or handle hauNouo mamim Re-roofs as defined by the Cupertino Municipal Cola,Chapter 9.12,and the Health and Safety T e of Roof Cade,Section 25532(.)] YP Ya Will me epphcut«foam Wading occupied rax e9oipmcm or devices which All roofs shall be inspected prior to any roofing material being coilh,vdaus arm roderin, final by the Bay Area Air Quality Management installed. If a roof is installed without test obtaining an inspection District] �x` I agree to remove all new materials for inspection. Applicant ❑Yes No Ihavc mad the huedwo materiµa requirtmcnn underChapter 6.95 of the Cali. un erstands and will comply with all non point source regulations. frena Halm&Sµny C .25533 end 25536.1 undmuM met if me belmngdoesnacuantlyheveatuu 'biliryurwtity the«cvpant of moments which eofeC 'fie `fO,upem. Signature of Applicant Date .smo s Date All roof coverings to be Class"B”or better OFFICE