00050072 CITY OF CUPERTINO - PERMIT NO.
BUILDING DIVISION PERMIT CONTRAGTORJNFORNATION: O bs
H U ILDING ADDRESS:
0435
J r ��. �1 IU— / /NC SANITARY NO. APPLICATION SUBMITTAL AT
OWN";SNAMIJ /ads Rear �F`�. NIC 5-4-00
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ARCHITECT/ENGINEER`7 _/ BULGING PERMIT INFO „
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LICENSED CONTRACTOR'S S DECLARATION
Z O v",O�O 1 hereby df.Wt 1 t3 licensed provision of Chapter 9(commcraing Job Description
mF W with gallon]000)of DiviaionJaldm Business and Pm s s ode, h1y llcenseia
$—$s in fnR fn a roil eDttt.
%ce O Y.1 U License Conti
EEE Dam Conu¢mr
h_p G ARCHrfF,CPS DEC6I
v� J ret mY I be uud as public rcoords
wa00
L
n uaS^ a OUILDER to
C < f hcmby anon Natin I a.em 7.empt from Contractors License taw,for the ,
Z ❑ following own.(Section]OJ L5,Bminm and Ptafmiws Code:Any city or county
.
Sas Men rceaims.permit m cmnwn.alter,improve.desnofish,m repsir any atrocious,ratrocious, S Ft. Floor Area S Valuation
c. pomto its lfaWOea.elsomqulR0a
5m pplicant for such pemut m file a signed statement q'
Jut he is licensed forhydand 1.the provisions of the Contractus'.License Law(CMges 9
(wnoruneingwithSasucut700)ofDivision3eflbeBusinessandemfersimsaCeae)Or APN Number - cc��panc Type
Wt he is exempt Naeftom and the basis for the alleged exemption.Any violation of r-g Y YP
Section 7031.5 by any applicant fora pemot subjects the applicant m a civil penalty or l/g./, fY✓'�
Qt more Nen Eve hundred doll.(5500).
Lasewner of the property.or myamployaca with wage as their sole wmpemaoon. Required Inspections
will do thc work,and the shunute is tet uncoiled oroRemd for sale(Sec.7014.Business
and Profession Cod4:The Contractors w
License law does t apply to an Owner of
property who builds or improve therwn,and who does such work himself or through
his own employes,provided Jut such improvemenu rue net intended n offered for
sale.If,however,the building or improvement is sold within one year of completion,the
nmbuildtt will have the written of proving diet he did not build or improve for pur-
pose of We.l.
1,u water of the property..exclusively connected,with licensed c..to
construe,the project(S .7004,Business and Profeastons Cade)The Conti uu,Li-
came law asci not apply to an Owner of property who build.or imleoves thereon,and
who connects for such pmjmu with aconuacta(s)licensed pursuant to the Conoacter's
Litton law. j
❑1.exempt under Sec. .B&P C for this reason
owner Dam 6/
WORRF,R'S COMPENSATION DF.CTARATION egr��/'�
1 hcmbyaffdrmunkrpanalry Cepa Cor oneoftheinsursogworiceiau: V
1 have add will maintain a tion 11 to Of theLaw,erato self-Codc,�um forwoorcha ce ropen-
01 Ile
sation,as provided for of Section 0]00 of the Labor Cade,for the peAomunce of the
haforve
which his pttiouis iolise
roti 1 sued
have end will maintain ice Comp niche n Imur.e,as requited t i Section
of the labor Code,for the performance niche work for which this permit is issued. ,
M Worky curio and policy
.
Cartier./f dg( PolicyY NFIR
CERTIFlCATEOF FSATION INN FROM W RKERS'
COMPENSATION be cop SAT10N INSURANCE
(Thies section need ice h completed if the permit is fmona hundred doll.($100)
cor los.)
I certify No.the performance of the work fur which thio the W is issued,)shall
Out employ any Canon is any manner so.,ro bcwnm.wbjet ro the Wohara'Compcn-
Apion Laws of California.Dau
Applicant
NOTICE TO ct to to W.d If,dour making this Oskno of of Exemption.You should
become su.,y the Wodmfa Compensation p.II shal of the tabor Cade,you masa
foMwith comply with such provision or this permit shall h domed rtvokW.
CONSTRUCTION LENDING AGENCY
Q 0 I hereby affirm Uro them is a construction binding agency for the perfomunce of
Z the work for which this permit is issued(Sac.3097,Civ.C.)
14 unities Name
j Lender's Addrtsa
W1 certify that I have read this application and We Jan the above iation is
0. '� corteet.I agora to comply with dl city..it runty ordinances and state laws misting to
U O building construction,and herebyawhorim eteti
reprenvm mm
Of this city aer upon she
above-mentioned progeny On inspection pusp tae,
Rr Fes„ (We)agree no save.indemnify end kap bamlese the City of Cupertino a8s1m1
[1 liabilities,judgmen,cru and expenses which may,in any way same against said City
yr lis: in consequence of the granting of this permit.
F M. APPLICAN'tUNDERSTAN SA Nit WILLCOMPLY WAIT ALL NON MIN'I'
f..) z SOAR.F.RFC,. IONS.
site]
Si of A,fi ant/Cwtractn I DAn
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ocwpant store or handle harardous meourial Re-roofs
e defined by the Cupertino Municipal Code.Clupeer 9,12,and ties Hath and Safety
Code,Saricn 25532(a)1 V. Type of Roof
❑Ycs
Will the topic.,or future building aaeep.n as.equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hararAous air wnuninanu a.defmd by the Bay Area An quality Managensn installed. If a roof is Installed without first obtaining an inspection
'^01' I agree to remove all new materials for inspection. Applicant
❑Yes pp ryo g
I noround thc lisardws mamdals tryuircomnu under Chapter695 of the Crh- Understands and will comply with all non point source regulations.
Ionia Health&Safety Code.Sections 25505,25533 and 255)4.1 understand that if the
building docs nor eurmm1 navea ten d,thtItianym.pomibiloym.inn'theacupant
oftherent d thmt 'n Iasuaned•ccoftnmpfo¢'y y
Mari/illi.!/ Signature of Applicant Date
age tIf loam
All roof coverings to be Class"B"or better
OFFICE