08070142 CITY OFCUPERTINO
BUILDING DIVISION pgljMIT .k�C01�ITRt1C C?RIA1T1`C}T,in 10
BUILDING ADDRESS: PERMIT NO.
18 /60 Tr LSON AVE TBD - TO BE DETERMINED 08070142
WJR'S NAME: PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
ARCHIECDENGINEER: - BUILDING PERMIT INFO
BLDO� ELECTO PLUMBS MECHO
300 LICENSED CONTRACTOR'S DECLARATION lb Description
U g 1 hereby arRrm that I am licensed under provisions of Chapur 9(commencing ofSCrI p
]1 with Section7")ofOlvision3oftheBusiness and!ProfessionsCode.and myliccmie HOUSE DEMO APPRX 1078SQ-ALL TREES SHALL HAVE
o� iiceneClaand arreat PROTECTIVE FENCING DURING THE DEMO PHASE.
License Clsss Corg
Dau Can
ARCHITECTS DECLARATION ARATION
nu
1 uakenJ my plans Shell M used as public rornrth
a
1 Licensed Professional -
OWNER.BUII PL Fr DECLARATION
1 meso (Sect Nal Pam exempt!Bu the Cssions od License law for the
D O fallowing moon.(Section 7M i$Business and improve.
damli Cada:Any city or rounry
$ which requires a permit Be requires
dct alter,improve.dpermit,ser repair ed ammo m
Za that heparlor 0
isswnepersnalto to thovisioumfaf sugh Cmunscho,Las st Law(Chapter
�< Ihathe is licensed personal lothepmviAsm of the Canuamr i LJcem lClmpta9 Sq.Ft. Floor Area $ Valuation
B (commencingaI,extwWSecfroan nd)of basis n3 the qcd Business and Poorest..lation of - 10000
.. Natio u exempt therefrom and or buss for du 03 the esemant to Any violation of
Section 7031.5 anfive
airy replicant for a Iurmlt objects du applicant la a civil penalty of Number Occupancy Type
not mass Nov five hundred dolurs(55110). 37517040 .
0 Las owner of Ne property,m my mployce with wages u titeir sok compemdon,
wiBdotheworkud NesuunumumtimmndedoroQemdfarlate(Suc.7H .Bxsimu Required Inspections
and Professions Code:The Con ercmn rs Licem,Low donot apply m e ns an owner o! q p
pmpeny who builds or improv themon,and who does awh work himself or thmugh his
oweemployce,provided that much improvements ate not intended oraEemA(orale.If.
however,Ne building a improvement h sold within one year of campledon.the awner-
builder BAR haw the burden of proving that he did But hued or improve far purpose of
ule.).
Or 1.u owner of W property am exclusively coni ting with licensed annuutou In
construct Ne pmjea(Sec.7044,Business and Professions Code:)The Corginsu fs Li-
am Law does not apply m an owner of property who builds or improves theman,and
who contracts for such projects with a contractor(s)licensed pursuant Be the Contractors
Lieem Law.
0 1 em exempt underrt$�p�cs,[5� B&P C for this resson
Or \V'v" DauAD
TWO KCER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one or the following declensions:
O l ham and will mainuin a Cmn Pmo of Comnt to ulf-insum for Workers Compen-
urine,as provided fa by Section 3700 of dm Iaba Code,fm the performance of the
work for which this permit is issued.
0 I ban and will mammin Workers Compemdon Insuram,u required by Section
3700.1'Ne labor Code,fm me perrormuceofthe work far which this permit is issued. '
My Workers Compw don Imnsm Cartier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thts$Ogden need not he Completed if the permit is farom hundred dollars($100)
or Ins.)
I certify Net in the perfmmama of the work for which this permit is maxed,)shall amt
empiuyanypersoninsoy,M-25 �bcrgmg subject m the WerkW Compenudon
Lawsof Caliloroia.Date / 77
Applicant 4O 6 '�
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you Should
become subjm on the Workers Compensation provisions of Ne Labor Cady,you must
.J O forthwith Comply with such pravisinm a thus permit Shall ba damed nvaked.
CONSTRUCTION LENDING AGENCY
f-' 1 hereby.Mon this dart is a Conwuctinn Lending agency for the Performance of
6i the went far which Nu permit u issued(Sec.3097.Civ.C.)
W Lenders Nona
]z, Landers Address - -
(.)Q I cmtify that I have mud this application and sum that the above infarmNun is
ty F COMCL I agree In Comply with Al city and COSIMY mdimaucs and sou rows Misting IS
.p C) building construction.and hereby authorize representatives ofthu city to enter upon the
above-memm and property for inspection purpoms.
(We)acme Be sew,indemnify tib keep harmless the City of Cupertino against
a.y yz lkledlifies,judpmenu,coau andespemu which rosy in Buy My mene.gaiml and City
in
Of the granding Of
V^
APPLI
CANT eUNDERSTANDS ANDWILLWILL COMPLY WITH ALL NON-POINT Issued by: Date 2
SOURCEREG
�� of zq/oy
Re-roofs
Signature ofA can nRamr Orte
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or(utuu building mcuputatom arhuate haallom material
Bnad by the Cupertino Mundpal Cade.Chapter 9.13,and the 1441th ted Safety -
e,Suction25532(a)T All roofs shall be inspected prior to any roofing material being installed.
0Yu Mm
WILL the applicant of future building occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
emit JUMMMxs air conumimmm u de0md by the Bay Area Air Quality Management all new materials for inspection.
Digric@
0Yu Ople .
Ihaveread the has nmwdalsmquimmcnuunderChepur6.95afduCalifer-
niaHmith&Safc,yCede SecdmU5W,35533 av125534.1 undcumnd deatifthe Wilding
does nal curmmly haw•teguL that it IS my mspomihilitY an notify the occupant of the
mquimmentswhich mug be met primlo issuaueafa Corrifcame of OccupwL Signature Of Applicant ' Date
oa;JSUI
Owner ora .road agent DauAll roof coverings to be Cl ' "or better
' g ass an