00030142 CITY OF CUPERTINO PERMRNO./ r
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADI�Rtt� �s ` W ✓✓
//� _ A _ _ � `W�rYI S SANI'1'AHY NO. APPLIC TION SUBMITTAL DAT
Lc i 11 LD" C-&P-U V/y/y1� S. hll�Gl�L-� 3 "TR cJD
/� L-� N/C CONTROLB
PHON::: I �J��I � 1 dDisc R��2� � .
C9,L5 / BUILDING PERMR INFO
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F '6^ LICENSED CONTRACTOR'S DECLARATION
z Uyi Iherebr.f,.th.l l am limmandunder P.Wor.of Chapter 9(Com -mg Job Description
O�', w with Secdon90W) fD"'on3ofthe Bosinesswd Pmhssioa Cotle.e my license is 1 \
ayt'' in full force andCR�u,.��-�5 .d/'f1� 1/ w `\lest
pr e a IJccnx CL a a t S3_tJc.« N`"— l "1 e-1 GZ1._JlJ' Vw�J
iu 1- Dec. Co.----
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ont" - /� nom,
C��� nntand mall bet SesEV bRA + �V I f Y S a• a l�� �i�J(
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a Inc4busistamitioncrinst
p�R O -BUILDER DEMRATIO
Z 1 hereRum by, I exempt from Ne Contractor'sCritic
License Law(m me
a
5 S p fa110Wing«awh(Sect on l .S.BY,IM,S and Ph
m ,llOn9 Cede:AnY Cltr IX COYnty
u'7 C3 m which rtquim a permit w Cauwct,alter,improve,demolish,o,repair any namom e S Ft. Floor Alia Valuati --
prim N ins,nuance,alto rtquireathe applicadt fonucM1 pemtit N file aligned staxmem
Net he is liceaued Panum,to Ne Previsions of the Con'&.Licrnx taw(Chap,9
(commencing with Smuon 7")of Division 3 of me Belneas and Prufcuios Cods)in Number Occupancy ype
Net he is exempt therefrom and Ne basis far me alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit ubjects dte applicant a civil penalty Of
pt more Nan risehundred dollen(SSW).
I.sown,armeproperty.armremploY�•wiNw,gea..meirWerompen,.tian. Required Inspections
will Profession,
Code:
The tureistmt inundnd, an,dos Wapply to a4,Business
and property
CO,or The improves
s Licenu law docs na apply tom owner of
his o ny who builds Or improves merchn,and who does such intk al Or or through
his own emPlay¢r,Provided r m such ment is sold within
are no intended oe offered for
We.lf,howcv
will
buildingmimprovement issoldwithinoneildini prove forthe
owneeW il..) will hare the buNen of proving that he did not Wild or improve for pur-
pou u t anal..)
I,u o r of the pmpcny,em exclusively conuxting with licensed Conuacmrs to
sea.Le the Project"iy ,ace wet of end Professoriat Code:)The Conaanor'end
apse law alae,nw.pply rot e,own,of ptwenr who wdh Or impro.,mmeon.and
whoContracts for such pmj«u wiNacona.ctw(,)IicenrW pursue,to the ConuectMs
Licenu taw. /
❑lam cumptunderSec. .06:PCfo1mil reason
OwnerDox
WORKER'S COMPENSATION DECLARATION
1 hereby affirm took"penalty of perjury one of the following declandi.ru:
❑I have and will maintain aCmihcate of Contemn self-insure for WorkCta Compen-
sation,an provided for by Section 3900 of Ne Labor Code,for the perfo"name of the
work for which Nis permit is issued.
I have and will maintain Wool Compensation Iruummd .in required by Section
Im Of Ne labor Code,forme perfwmatc,cddrc.,it for which thin Permit is iamed.
My Workers C m enation I...rm a ani,and Policy u
Polic
No
C.mier� fill AM F ) PTIONYFROM Mo.' . _'b
COMPENSATION INSURANCE `i!V 1-Cc
mn,smooth mind ries W Completed ifthe pemtit is for me hundred doll,,a IW)
Or less.)
1 Certify Net union performance of me work for which Nis permit is issued,I shall
not employ any person in any mann,m as N became subject to ore Workcri Compcm
cation laws of Califomi,.Date
Applicant
NOTICE TO APPLICANT:If,after melun8 Nir Cenificete Of E Ccrpo m.you should
become subject N Ne Workcke Compenution provisions of me Labor Code,you must
forthwith Comply with such provisions or Nis permit shall W demand revoke,
CONSTRUCTION LENDING AGENCY
OO Ihereby inn Nat there is a construction lending agency forme perfmmadee of
r., Ne work fm which this Paton is issued(See 3W7,Cie Q
(anode Name
K lander',Addre.,
[.] 1 certify that 1 base read his epplwtion snit...that the above information is
6. zC.I.I agree m comply wim W city and chtnty otdimance."...laws rtlming N
= z buildingcon,vucuon.and hereby audience representative of this city to enter upon the
V Q above-mentioned property for inspection purpose.
k. F.., (We)agree Neave,indemnify,end keep harmless dx City of Cupertino against
Q V liabiliues,judgmems.most and expknxs which ay in any way eccme agalnn aid City
f Liz in consrynencc of dx granting oft' perm
[� C, AVYLIf UNU HSfANis 'N .I.COMPLY IT{I LL NON-POINT
BOUR BPC.U'A9'IONB.
v z Z2
Simeone of ApplicmUConuaCtmIf Dox
HAZARDOUS IVATEKiAf,s DISCLOSURE
Will meepplican,or futum Wt ing pens store or handle hara"dous maxnal Re-roofs
ed dcfinc l by the Cupertin.Municipal .Chapter 9.12,amt the Henth and Safety Type of Roof
endo s,tioh zss3x.n Yp
Yc, ;No
Will me applicant future Wilding Cmumm use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit luzvdousairCoeaminann as defined by In,Be,Mea Air Qmduy Mmupemont installed. If a roof is Installed without first obtaining an inspection
District' I a ree to remove all new materials for inspection. Applicant
[:]ye,
I base re:d the h. dna senate regtinmenn ander Clepxrb.95 afinee h. un erstands and will comply with all non point source regulations.
Tatou HeaIN&Sefmy C ,S,uons 25505,25533 and 25534.1 understand that if rhe
building does not currently have a tenant,that it is my responsibility to notify Ne occupant
of Ne requuemenu which mon be met prior N umance of a Cenificate of Occupancy.
Signature of Applicant Dale
rywn<r m euNonznd agent
use
All roof coverings to be Class"B"or better
OFFICE