00030150 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRBS$: 1 /�
/sem/'J/{,rte (/( SANITARY NO. APPLICATION SUBMITTAL DATE
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Z O H i LICENSED CONTRACTOR'S DECLARATION Job Description
O Z V C 1 hereby aRw the 1 w liumed under pmvisiona of Chapter 9(commercing p
p:_Cm wish Section 700E.Mivlsion 3 ofthe Business and Prof<nioesCode.sok my license is
d in full force and e -1 r A
E:aswO I six Ch. Uc.M
3 i F Daa "CH=S
/]7 .
[-.a O to ARCHITECTS DECLARATION /7
'^-t I understand my Plans shall he used u public records C
c. l/
o.e,o LicrnsW Professiwal
'u5^_,�, OWNER-BUILDER DECLARATION
F Ga 1 hereby.Owe that I w exempt from the Cortracfessi.tCo License Law for de
folimvin8 mss^^.(Sca'tim'ro31.5.Business and!Pmfcvimu Cade:Any city or munsy
w C which require a pmrnh re<m,.tmcl,alter,none.,delmuah,or repair any a-- S Ft. Floor Area Valuation
c. pnmm its issuance,also reports she Wiliam Watch Permit w file eaimedalatcment q-
thatheislicensedpmavantmNepmv sof the Commucona License Law(Chapter 9
(commencing Wish Secdne 7")ofUlvitlon 3ofthe Business and Prefeaiana Codc)m APN Number Occu T
that he I.exempt diversion.sand Ne basis for see alleges exwpuon,Any vioatiencan or/ p P Y YPe
section M31.5 by any applicant Insulation'subjects t o applicant in-civil Penalty of
.in ons.then fvc humhcd dollen(5500).
❑1,aaawnerardaprepenY,ermrempmyeeswithw.gwaNcdml«emPetanen, Required Inspections
Will dofa work,modthe eche Cm istotintendede Law don,
apply Iona,moser a
W property
whom Cade:The C ar Chasm i Liume sew docs rwr apply a if owner gh
propcnY who builds or improves Hereon,rope who does such work himself or through
W,own owe er.thu bunvidok Ws such impros sold within w nor iaeMed a o6<rok for
Wel-howevccthe Wil dingmimprovemcnt ithat hedon<ywrintermittence,improve
rpui
posix f udder will have d¢burden or proving that he did not build m improve for Fur- J/
pore a aleJ. �
I,u tme of the property,.B exclusively contracting with:)licensed conm\eton ro
combvw meMi.,(Sec.o as,owner
ropers,who
Cores:)TheCwherson, nil w
who contracts
dew nor apply je an owner or pepens who sed per ant iorw Cormsm end
whooss,Laws far mcM1 protects with a coronations)licensed pursuant m Ne Canuecmns
Licgnse Law.
❑IwexcmPtuMcr Sec. .Ba PCfor this season
ter Dal
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Fatuity of perjury one of the following declwtiom:
1 have end will maintain a Certificate of Comrnt to self-iname for Worker's Courtier-
Wine.as provided For by Section 3700 of the Labor Code.for the pertomunce of the
work for which this permit is issued.
I have and will maintain Workers Compomstrom Immense.as tequbed by Scclkm
J)00of tM labor Cade,fa Ue peofwmaotcgof the work fm which this Pewit is owed.
My Workcn Co c tion Ina a Q<un'pr end Pollcynumpy !I,
Cenicr. ey No.
CERTIFICATE OF E:EMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
(This sccdnt modem he completed irde yemd,is fmone hurmcd da Iw(S100)
m lea.)
Ioyany that in the any member blithe workme,oijuthis pew itisissued,)shall
nm employ any Person in any manner m as to become.mbjecuo the Waoken'Gemp<n-
mn ew
s of Caiifmni\.Dora
Applicant
NOE
TO APPLICANT.'11 atom milting this Certificateof m Ulne, on,you nshould
comic
become subjecty de Workers Coons or
is pmviti hal of tba Labor Coke,you must
forthwith comply with such previsions ar this pewit shell be deemed revoked.
CONSTRUCTION LENDING AGENCY
O I hereby affirm that there is acomwetion laraingagenry for the pcoll . of
Ne work for which this pewit is issued(Sec.3097,Civ.C.)
I.., LaWana Name
} IeMcr's Address
W 1 unify thin,1 have read this application and stat,that me above information is
C. 0 cmrtct.I agree to comply with all city and county ordinances W au¢laws rtlasing to
LD Z building continues..,and hereby auJtorire reprtaznmivw of this city to anal apart the
U O above-memioned mr,dy for inrpectien purposes
W F (We)agree a nave,indemnify end keep hawlem the City of Cupertino agaimt
O V liabilities.judgment,cost do which my in any way acme against soil City
} ;4 in coroners e M the B ti of thin permit.
(• 0- APPLICANTU ❑IiN DS AND WILL COMPLY WITH ALL NON.( INT
U Z SOURCE
- 3 ^'�
Slgnetae ar ,hca /Centraetm ° /�2, AV70?voc i rf!{
HAZARDOUS MATERIALS DISCLOSURE
Will Nse.,ficint or faturt building acugntstoe^r haMle bartenders ntaanai Re-roofs
a defined by the Cuporm.Municipal Cres.Chaptel 9.12,and the Heshh and Safety Type of Roof
Cade.Sarion 2553241? YP
❑Yes E]No
�1 Wilkie applicant er fuwrt Wilding occupmt use equipmcm mdcvi<es which All roofs shall be inspected prior to any roofing material being
ha ickous im<ontwitaaaa.definedbyibeBayAreaAnQualityManagement installed. If a roof is Installed without first obtaining an inspection
nai7 I a ree to remove all new materials for inspection. Applicant
,i ❑Yes No
I have, teh 1maa",la aquiameta under Chaptw:,.95 of�<G.l,- un erstands and will comply with all non point source regulations.
anotia HUIN a safely C .Secitima 25505.25533 ape 25531.1 uMmtad tom if the
(wilding doesna cu of.treanl dust net my nspmnibdny,a maily the recipient
of the men s muss he me,pna to issuance of a Certificate n (Xcu y.
Signature of Applicant Date
OwneirminksbarOuti,ein D
All roof coverings to be Class"B"or better
OFFICE