00040150 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INF.ORMAATION: C)Ia0 9 L/ 0 1 fl
BUILDING ADDRESS:
SANITARYNO. APPLICATION SUBMITTAL DAT
O NEft'S NAML: ,a
•
/�/// � �9%/S,—
ARCHITECTIIiNGINELR BUILDING PERMIT INFO
M00 C
5W5 I
6^ LICENSED CONTRACTOR'S DECLARATION
0Ham—, 1Wabyaffirmchat 1smlicensed under provisionsmfChapter 9(mmmmeng Job Description -
1-=CW wish S«tion7000)of Division3oft Businusand Professions C.de.aedmyliccnais
Y in full force and eRcet.
y p y 0 Li«nas Clw Lic.a
x 3 N Das Co.tr.cwI _ /^\
F=O g ARCHITECTS DECLARATION
1 uvdenaed my Plan CHI W TS u public TION
w
n 0. O Li enW Professional
OWNER-BUn.DER DECLARATION
t 1 hcrcby M.that 1 am exempt from she Contncrols License law f«the
o following=Sm (Section 703 1.5 Business and Professions Code:Any city«county
2 which houses a permit in conlocL alar,improve,demolish,or rcpalr any s.I. Sq. Ft.!,,,pppr Area Valuat n 00
Prior to its lrmarce.also rcquims the applicants foramb pmdno file.signed aoamem ^ p0
that he is licensed pusuam to da provisions of the Contractols Licence law(Claps 9 V V
(com enceingwithSection7000)ofDivinion3oftheBusincuandProfessionCode)or APN Number Occupancy Type
that he is erempl therefor,sed the suis far the alleged emmptiom.Any'violation of e�
Scchoo 703 L5 by any applicant for a permit subjects the applicant to..wil penalty of
Ven f sic hundmd dollen(5500).
ir.fthe promny,or my employees with wars as their role compensation. Required Inspections
will doth.work,andth The Comic tui Lit.Lim do r«ole(Sec.7044,Boaimrs
and Rofessimo Code:The ov.thcwr's Liceroe taw doer rwl apply w an wvtar of
prop.y wW buildi or iop.ver t h I W wW d«s such work dmsel!«through
......ployee.,ptaddnd that such impommenw art on Intended or maned for
We If,M1owemr,tW Wilding or improvement is coldswithinione year of ompletfor the
weer-Wilder will have the When of proving that he did net Wild or improve f«par-
- pose of I.I.J.
0 1,as owner of the proprty,stn exclusively contracting with licensed commons an
comswcs the project(Sec.7014,Rod..and Profession.Cade:)The Contractors Li-
m.
men law Amen...lyto an owner a property who Wada nr improver thereon,and /
wbocontracts for such projects with•mntces m(s)licensed Nouant o be Contrrcwts ^�
License taw. V
❑1 c funder Spa. _.BkPCf NiNis�r,wy.�n a�
ECLARATION
1 hereby nm undo Frnvry o!polo cf the folltavimg decluetimu:
�1 bre nisei WIII mainain.Ccnlfiva Of ConelHm ulfittwrt fm Wokcta Compen-
ation,r p.vidd fm by Seati«JT00 of da tab..Cale,f«the perfonttance of the
work rave which this ands is issued.
37 I love end will ore,for Wodela Compensation work
for ce,which
h recthis pen by Section
My ofrhelabor Core,for thepRacremeofthe wart forwhichthinpnnit isiaaueA.
My Workers Cmmpnsation Innrance canierand Policy number ert:
Cartier: Policy N.,
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
Mm«
rlhi.eindrd be completed iflW pout I,forces hunArd"Ism(SIM) '
or
1 ecrtify that in the Frrfmm.rce of the work for which this pmol is issued,l shall
not employ any From.in any charter So as to become,mnect to the Worker'Compen-
sation Laws of California.Dare
Applaam
NOTICE TO APPLICANT:lf,after making Nis Cer ificaa of Esemplion,you.hould
Immo subject to the Worker's Compensation provisions of the labor Code,You most
forthwith comply with such provisions he this .I,"I be demand revoked.
CONSTRUCTION LENDING AGENCY f,
Q I hereby Wfitmthat Nert is a curmwcdon lending agency for the performance of
Z the work for which this pion is issued(Sec.3W7,Civ.C.)
Leader.Name
a > landeR Aedrtss .
ry) I Csc ily that I have tend this application and mar, Ra
e et above Inmm
fuUOm Is
L z C.I.I eg.w comply with JI city and county orthotic.W.ate laws rtlmogi m
s7 7 building construction,and hereby malwrice rtprnentuives of this city to enter upon the
U above-mentionnd property for inspection purposes.
W F., (We)agree to ave,indemnify and keep hemleas the city of Cupertino against
0 O Iiabilities,jodgments,mom and expenses which may in any way meme against mid City
>. W in<onvqucrcc of the granting of this ptmit.
[r a- APPLICANT UNDERSTANDS AN I)WILT.COMPLY WITH ALL NON POINT
NJy/,(/.1•_rtc,IJ/til\ifWIATIL!f.
U ti i5 a
ofppbcaMContnmor Grow
HAZARDOUS MATE0. . DISCLOSURE
Will a applicant or future Wilding occupant store or handle M1auNous maarid Re-r0 s�
as definal by the Cupertino Mmi ipal Code.Chapter 9.11,and Nc Health and Safety Type Of Roof
Code.Section V5532(0? yP
0 Ye
Will thd applicant It,fourt Wilding occupant use equips«m or devices which All roofs shall be inspected prior to any roofing material being
t hazardous air memanotmos as defined by Ile,Bay Arc.Air Qualiry Management installed. If a roof is installed without first obtaining an inspection
District? remove t' / I a ree to reme all new materials for inspection. Applicant
m c 0 Yes C4 g
(have hand the M1aredoe,materials mgaiamenn mtder Cape 6.95aUse Cali- understands and will comply with all non point source regulations.
roma HW in B Safety Code.Snvmu 25505.25533 and 255X.I m1dnMLld that if the
WiWin der.as cu ail n t."itismymspomibilirywmifyt mcupant
Daa
p All roof coverings to be Class"B"or better
OFFICE