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00040019 CITY OF CUPERTINO - - PERMIT NO. BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: robuN db l BU{{{{{{LLLLLL��DDDDINGADDRESS: - (�O ^� r (1�n SANITARY NO, AYp1.IC5s `/�`ATION SUBMI AL DATI IIJJ SVl vj ' OWNS 'S NAMC: �5 t:✓1 I h � Cl: {`f Ian L� CYT N/❑C CONTROL# ON!:: ^� c O — JU I sc ARCHIT HCf//F:NGINEF:R ass- IULDING PERMIT INFO 9� F dOi LICENSED CONTRACTOR'S DECLARATION O'0 v=4 I hescby Rffam that I w licem<d ander provisions of draper 9(emm.in, Job Description wimSection 7n00)ofDiviai SofrW Buaine,sudPa/essienaCode,aM mY lice&eis /` ,f —C's in full fortt anti air l/_/V1__.a �� � 3G YS� Y1 /tJ_ DRIT la Cmite 3 0 N Darc Convenor "`r u O g ARCHITECTS OECIARATI N ` /✓� j,n 5 I understand my pew am be used u public reads a i o O Iluaad ProfcuimW c seas^ OWNER-BUR.DER DECLARATION C a 1 hereby affirm thn 1 am exempt tram the Coal..',License Law for the 'r C following roan.(S«lion 7031.5,Busimu and Profession,Cods:Any city m couary R.3 w WWell amounts a Pound,so ceatract.Won.imprnKmm .deolish, repair my nmember Sq. Ft. Floor Area Valuation prior to its issuance,also requires this applicant for such Pemtil a rile A sigtr-A automaton ! JOVA_ v l that he is Beamed pnaumt to Nmmm Ne provisions of the Ctob License Law 9 y V (commencing with Section 7000)ofDivision 3ofmcBusiness and Professions Code)us APN Number Occupancy Type Wr he is exempt therefrom and than basis for the alleged exemption.Any violsom of Section 7031.5 by my applicant for a permit subjects live applicant to a civil laundry of I t rtwr<Jun five hundred dollars ISS00). wi I, she war of me poprr.m tar in wage u We (Sm.compewtiw. Required Inspections will domewmk,on,due etrucmristrotintendedm Law fan (Sec.7 im Business am Profusions code:Tho eonwnor;License law a&e ata apply to lf aldncr of In'o property who builds or improves dierehn,red who does such work himself 1 through his own employees,provided mm such men-I,menu ere ata intended m oRemd for ane.If,holder!,the building.,heimpovemenrisaid within nueild or i prove fon.Jr- eof"leer will have Jr-Wrden.(pressing dial he die ata Wad or improve for pro- pose of"le.). � 0 71 I,as owvar of the propcny,sm exclusively convecting with licensed contractors to construct the poject(Sm.RNa,Business and Professions CWc:)The Convector's Li- &c / ceLaw due. apply Re an owner of popery wed Wilds or improves datum,sM wed contours for such projects wish•coatrecto0s)Beamed pumuent a no,Contractors O License law. s^1 I am excmp undm Sec. .B k P C for oris mason owner Data WORKER'S COMPENSATION DECLARATION I hereby affirm under poulry ofprjury one Of the following dmlaratiwu: I love end will mainuina Car ifiom of Com sed In r<deimure fmwmk<raComp.- o nion,as provided for by Section 37d of the Labor Code.fm the performance of On ork for which diva permit is issued. ]1 have and will maintain Workers Compensation Insurance,OR requioA by Section 700of die IaWr Ceae,fm ted prformsme i f the work for which Nis Pernrl u tuned. My W. ' comp.aaaen li p upyr-c c 'erPo Policy.: � _ZJ 2T� Gerrie.: crOrer/J/L�� CERTIFICATE OF EKEMPfION FROM WORKERS' COMPENSATION INSURANCE (This secu nneed..be completedAdis permit is forese hundred dales(SIM) or leas.) I redify that in the Performance of the wok fmwhich Nis prmil is issued.)shall rot employ any person in any manner an as to become subjmr to dr-Workers'Compn- .non laws of California.Date Applicata NOTICE TO APPLICANT:If,afar making this Cenificate of Exemption,you should become subject o the Workers Compnurion provisions of die"nor Code,you mon forthwith uunPly with such provisions m this Permit mail W datrcd rooked. CONSTRUCTION LENDING AGENCY O C) Ihereby affirm that mete is a cormwcdon lending agency for the pMOmwe.of GGGZ y the work for which dos prone,is issued(Sm.3097,Civ.C.) Lenders Name } lander,Address 1 certify that 1 have rad this application and Rule Jul me above infordow"is a G coneda.I Agree to comply with JI city said county ordirwuesanalasum laws cluing to 5 z Wildingconapuctitur end hnehyaalani¢rtprceenu ,atesfmis city to env,upon die U O nWvcmemioned prapry Me inspection puave, W (We)agree in Rave,indemnify and lump hornless the City of Consoled against O fF.) liebilmeajudgments,umuand<xprnacs which may in my way accrue Randall said City } W in consequence of ted granting of this Permit. nFr L APPLICANTUNDERSTANDS AND W .COMPLYWITHAI.I.NONPOINT V � SOURCIi RE'UI, Sipli VConumr Data FTAL3RDOUS MATERIALS DISCLOSURE will the applicant&form Wildingnmupenl store m lutdle haoNous material Re-roofs u defined by the Cupreum Municipal) me,chapter 9.12,and the Hualth and Sarety Type of Roof Code,Sm to.255320)7 / yP ❑Yes No Will ted applicant m forum Wilding occupant use equipment or devices whichAML All roofs shall be inspected prior to any roofing material being cmin haund0as m conumitunu as defined by the Bay Ares AB DOOR,Manegnnan installed. If a roof is Installed without first obtaining an inspection =11=,7 I a ree to remove all new materials for inspection. Applicant ❑Yes Ib.Brad the hausdou mmerad,aquimmcru ander Chapter 6,95 of die Cali- un erstands and will,comply with all non point source regulations. mu Health @ Sdny Code,Sections 25505. 533 sm 2553..I undnsupd that if Jr- uildingdoes concurrently have amoven,di a my raprous'IiryamiJy Jr-occupant of usismarets whin sea pew (e Cemfeem of Occupancy y 4—Cxi Signature of Applicant Date owner or Writ Dau All roof coverings to be Class"B"or better OFFICE