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00040123 CITY OF CUPERTIM) PERMIT NO, BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: BU DINGA�RPSS: S SANITARY NO. APP�ICA'ION SUBMnTALDATI OW :R)S NAME: 'HNIC CONTROL# ON': — _5 7 ✓({�v aY,& , C-.-.1i L4 3 0 6 ❑ CffilC/ENGINEER BOLDING PENMIT INFO Wq� Gso) 493 - 6, 3, 73 U <=w n LICENSED CONTRACTOR'S DECLARATION �O: 1 hereby affirm that I an licensed under provisions of Chapter 9 mommnrcing Job Description wish Smtion7f )of Divisio 3ofthe BusmcumdP fcuiom Code,Wmylicrosei, yet.Y E J in full force W eft-lJ5 Li<. / 270 Q T/0 less til- le . (�/ y Oec i License a # `-t' >�3 to Date C DECr 1� - ARCHITECTSS DECLARATIO d /� Iry �a s I mndenund my q.nx snail x erred a pubu<rcwta. /) n ° licrnsed PmfcuiorW u OWNER-BUILDER DECLARATION t=Z a 1 hereby affirm Ws 1 am exempt from Ne Contractors Licane,Lew for the 2 C following ttuon,(Section 7071.5.Business W Profeuions Code:Any city ter use, roun toC$ which rryxima a perech m camvucl,alter,improve,demolish,mr rcpa'u any rwcmrc 3— prior,to its iamance.also textures deW[icamfor such permilifile signed statement Sq. Ft.. Floor Area Valuation that he is licensed Wnuant m Ne previsions of the Contractors License Law(Chapter 9 (ommm[mgwWSection 70W)ofDivision 3ofMeBouneaWPm[abmcorAc)or APNNber Occupancy Type that he is cxcmp therefrom W the basis for the allegW exemption.My violation of p y •]P Sam.7071.5 by any applicant run.pemdt mbjecu rhe applicartI.s civil penalty of pI more Men five hundred dollars(SSM). 1,amwmerorf rise propen,Or my employea,wish wages as their sale compensation. Required Inspections will do Ne work,aod the amusum a is not i mended increment forsale(Sec.7010.Business and Profe,xiorm Code:Pre Contractor's License law does not apply to an owner of prone"who builds or improves thereon.W who does such wmk himself or through his own however. provided Thar such impros sold w are not iY—Of or,oRemd for We.IL howevm.11 h building ur ien cf,.em is sold within one yevof completion,she itwor "r-builder will love the burden of proving Nat he did not build or improve for per- poredule.l. ❑1,u owner of the property, exclusively emnlicensed mact construct the projen(Sec.7010,Business end Pro/eetioms Co6r)The Contnetore V. / nm law d«,ret apply to m owner a/propenY who builds ore impruvu thereon,and �� ❑Uc mnvacn forouch projecu withacontractm(s)liccnaed pursuant to the Conwcmre 0 lionlaw.exure empt under Sec. .BRPCfm this tractor O ma Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby aRtm under penalty of perjury One of the following declantiom: 1.1 have,W will msinulm a Ccnificarc of Comenuo sel6inmre for Worker,Compere lion.ax provided for by Satiou 7700 of the labor Code,for tax perfonmrca of the k for which this pewit is issued. love W will metown Wmkcr's C..'rootian Insurance.u nquiod by section ' 700of the labor Code,for the pcffonn eofthe work for which this permit Is issued. M Works' tion an[ cartim and Policyylm�p� ne�O Carrier:_� �_Policy No CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need nm b<cumpleted if Ne .it is fortune hundred dollen(SIM) or leu.) 1 emifY Iles in the penfonmarecofthe work forwhich Mispewit is iuo d.I stu0 am employ any person in any manmr mum become enbjecn or the Warkni Compen- sation Lew,orf Califoroia.Dale Applicant NOTICE TO APPLICANT:If,after making Nie Ceri Gent of Exemption,you dmuld become vubjwt to the Workers Cme,mrssion provisions of Ne Lubor Code,you forthwith comply with such provisions or this pewit shell be deemed revoked. CONSTRUC ION LENDING AGENCY Q Ihereby aff'w that Nem lsacomoictimn lendiogegemy for the pedowacc of Z the work for which Nix pcwil is Issued(Sec.7017,Co.C.) f'a teodcrs Name � ' Lender's Address 1 cimify that 1 have read Ibis application and sum that the about information is 0. 0 correct.I agree m comply with JI city W W s cost ordinances um laws rc4tingto Z Z building construc'don,road hereby authorize repmenlmiven of this city to enter upon the V 0 ebovcmcmioned pronely for inspection puryoees. k. (... (Wo)agra to save,indemnify and 4ecp humlcas the City of Cupenino against C V finhilidu,judgmmu.cm.and,espenua which may in any way secure against said City } fs1 in consequence of Ne granting of Uispewit. 'r On APPLICANT UNDIRtifA NDS AND WILL COMPLY WITH ALL NON-IY)INT � SOUNCE RF )IAT .g V `f/!9/QO / — �© Signature.(Applican onuscmr Date HAZARDOUS MATERIAIS DISCLOSURE Alnr= Will dteapplicwd.r furore Wilding ocmupml nmeof handle hazardous material Re-roofs a defined by the Cupertino Municipal Cods,Chapter 9.12,W the Health and Safety Type of Roof Code,Section 2f5731s)7 yP ❑arm lgK Wi110e applicant cur future building reenter,use equipment or devices which All roofs shall be inspected prior to any roofing material being emit harallousalr moumirou a defined by Ne Bay Aru Ah Quliry,M.,.., installed. If a roof is Installed without first obtaining an inspection L(d I agree to remove all new materials for inspection. Applicant Yes .vetidtheba„dxnmaatrial.�mbementrmWerChatter 695OfMeCali. un erst ds will comply with all non point source regulations. lth rrrffiswwq7)S///a'�'fety Cade,Section,25505,25533 and 25570.1 underswW that if the / oamrenl.that it is my msponsibilirymn the occupmtmrenl.that it is my msponsibilirymn the acvpant J' ill 00 ffichm sbe met Fm:u tt of eCfic�uin sbe metFm:u a of eC (c�uT��((// Signature of plical[ Date .athorizeda t D.te All roof coverings to be Class'B"or better OFFICE