00040024 CITY OF CUPERTINO - ; PEw`+ITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: V�U / / DU �/
BUILDINGADDAESS: /1 7 d-''f
of r/}—p� nV p//�CQ�. / SANITARY NO. APPLICATION SUB,M^pTALDAT
OWNIiR'. ME: IRl ll 1� lOL�7 VVV /J�t/f/11 NIC CONFRL#
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ARCHITECT/ENGINEER �S GUIDING PERMIT INFO
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AH v LICENSED CONTRACTOR'S DECLARATION Job Description
p =G 1 uereby alErm shat 1 em licenW uM r Provisions of C'lupmr 9(commencing p
F,_now wiNS«tion and
IF fDiv;sion3of Ne Buxin«s and Proreviom code.ab mYliumeis /�
< x m more WeR .� � Leg �Ul�aS p/�/(-1'Y[T^J
u.25..U IJanse
u.F DaIC Co.VacrIX
l=u.O•c ARCHITECTS DECLAICAT114KNI ,
v�a 1 urdersrand DIY Plant shall N uses as public minds . 1 aJ — /v/ 1
a er o licensed Pmrcuicnal
^_w, OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contr«ms's License Law for the
`e t�❑ following reason.(Section 103 I.S.Business and Fmfemione Chile:Any city or county
is= which requires a pmmin w construct.ale`•improve,dervelish•m repair any`t"re`"'e Sq. Ft. Floor Area Valuation
prim to its iasuence.also hotfoots the applicant for such permit to file a sig dmanceem r� rLl
Net he is licensed ponwnt no the provisions of the Comerwhes License law(C'hapsn 9 5•(JDU• ra../
(commencing with gemen7")of Division 3of6cBusiness and Professoriat Code)or APN Nboccupancy Type
and he is exempt therefrom end the basis for be alleged eman don Any violation an of P Y YP
Section 1031.5 by any appficann For a permit subjects the applicant w a civil penalty of
rot mom Nen Rve huadred dollma 13300).
❑I,am evock.the proshoutm myomplendedwithwagmu Ne(Sol.c)W.Box an, Required Inspections
will dothework,and the he Co.is not intended in`wit rm.apply.00an Buairneof
and Professions Code:The over domes License Law dura nm apply s lf owner gh
property sods builds pr improves Neuron,and who dons such woe himself m or Wd for
his own employe,provided n i each improvements is mid w ere raw intcaded m offered for
sure,If.however ildmwillrc buildingmimprovement is mid withinone yworwrovefor do
rf In).
n).will have Nc Incident of proving Net N did not Wild m improve for par-
❑poseeost,thn. </ U
h m owner of the property,am exclusively conn«ung vends licensed conoacmes to
construct theprojectpil,otan owner of Professions Cotle:l Treves omem. nd
Li-
once law cats«t apply no a owrcr orpropeny sods Wdde rs Improves thermos end
who cantruts for such projecu with a ronwcmo(a)licensed pursuant w the CanOacuMs O
License law.
I ans exempt under Sec. .B A P C for Nis rectum \/
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury oro of the following declarations:
1 have .it will mumaln a Certificate of Consent to self-insum for Whiter'a Compcn-
smion.a provided for by Section 3100 of the IaWr Cade,fm the perf n.of the
work rm�wll�th NIa panrvt is issued.
(moi ve rad will mountain Worker's Compensation Insurance.as required by Section
37W.f the"Nr Cade,for On perfro mon of Ne work for which this permit is issued.
My Wo 's m nasi tnstpPnce coy Pol Policy nyU 1),A ,,.,Sy�s.Q
Cloth Ina A �'+< Policy No.: f/A/Y
CERTIFICATE OF EKEMPrION FROM WORKERS'
COMPENSATION INSURANCE
(This sectirw need nal brcompleled lithe permit is foronehuMrcd dollars(SIW)
or lux.)
I unify that in Ne pedo..ofthe wink for which Nie permit is issued,l shall
rem employ any person in any manner ace as to become subject to Ne Wark Compen-
Wion laws of Calfomia.Dam
Applicant
NOTICE TG APPLICANT:If,after making Nis Certificate of Exemption,you should
become subjmno the Werkera Compensation provisions of the Labor Code,you must
forthwith comply with such provisions or this permit shall W domed revoked.
CONMUC ION LENDING AGENCY
Q I hereby uRrm that NCR is a conewctimi leading agency Nationperformance of
z Ne workfm which Nie permit is issued(Ste.3091,Civ.C.)
Leaders Name
7 IaMer's Address
rW 1 certify dsm I have read this application and`tire that me above information is
Q correct.1 agree m comply with ell city and county occlusions and main laws miming m
A z building conmmed...and berebyidhorice repmamitatives of Nis city m cnteo upon the
I.) C above-mentioned property for inspection pmrox.l.
Ls. E. (We)`goo in fve,iademniry and kap hamtlem the City of Cupmam agmen
(� lubiliuea,judgmema.corns and expenses which may in any way acme against mid City
;oo W in consequence of the granung of this permit.
:6 APPLICANT UNDERSTANDS A NO WILL COMPLY WI I A L,NON-POI NI'
U .L SOURCE RF,GUL1TIONS.
Signature mA omonctm Date
`HAZARDOUS MATERIALS DISCLOSURE -
Willthcappkrum rfumreboddo,ce-fromnoaorhmldlchersrelhamial Re-roofs
as defined by the Capmuno Municipal Code.Chapter 9.11,and the Heakh And Safety Type of Roof
Code.Stench 25532(a)? Yp
❑Yes ®Ne
Will the applicant of future Wildingattupmtt fere equipment or device,which All roofs shall be inspected prior to any roofing material being,
anon hamosom ah comaninanuex defound by the Bay Aura Au Quality Mempinunt installed. If a roof is Installed without first obtaining an inspection
°�"'Im"
I agree to remove all new materials for inspection. Applicant
rot dtheh,,.d�rasrotmomodsuder,Ghamr695oftheCali- understands and will comply with all non point source regulations.
feu lth&safety Coda.S«Yiom 25 .25333 and MM l understand that if the
Wilding does own currtnfl,ba Ice it is my resporuibilay to ready Ne occupere
err bot hoyfue a nce err.emigtme eroecumncy.
Signature of Applicant Date
Ownerm on'ra�e t Dam
All roof coverings to be Class"B"or better
OFFICE