00050055 CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION PERMIT CONTRACT.OR.INFORMA�'IIIO,N: " d Q SO os�5�
BUILDING ADDRLSS: {/(�,1 , 1
1 23 IJ. �IFe- M 2I 35^ O Neon SANITARY NO. APprc NSUBM
0,08
OWN3 N ME: (7 `/
^C- N/C0 CONTROLX
PHDN:: ❑
�T � - 4$004 {-I�yw+�/ C� 9yS41
t h.C'HI'1'1!C'1'/ENNGINEER 510) 5331903 CtctI0 53:1-k? BGLDIN PERMIT INFO-.. "I
�CO
teU�j
Gi LICENSED CONTRACTOR'S DECLARATION
_ 1 M1etehy affirm is L 'ions of Chapter 9(nmmercing ob Descri prion
tet_; wiih3a'�pa00B)af Sof Ne Business and Pmfeuions cenuris !/ �,� '�� ^R lS,�vsC�' ,sq
�:sEa _Ina. eaolc
emu a Lic.x /� �y/�(/� P
sf 3 c ate Contsanmr ! \` / // ` 13 o r\ (!
LL ARCHITECTS DECLARA N lr
ter I undanuM my plain tWlbausedm public ren
I�'a S.ff o licensed Professional
m^to OWNER-BUILDER DECL t TION S/�N Yr'_s, y VVV"'IIILLL••
t z a I hereby.fluters Nat 1 am exempt from de Convactof.License law for the
E O following reason.(Section'/fi31.5,Business and professions Cade:Any city orcounty
i 3$ which negainea a permit m cmarmuct.alter.improve.demolish,or topalr any mnctme re Valuation
pnwrO its issuence,also"or..to applicant for such permit m fileasigoed sutetsem ds p�
Nat he is licensed pursuant to Nn provisions of the Commissars License law(CTapm 9 i7 0
(commencing with Section)000)of Division Sof to Business erMP O ssioneC ApN Number cess arse Type
Nat he I,..Mi therefrom and me basis for to alleged e.cmption.Any vi on of n P Y YP
Seniors 7031.5 by any a,Iic.for•pemul ubjech,the appliunnO a civi ry of /OO }
no more Nan five hundred dollars(5300), we'
❑I.as owner oforepropeny.mmyemployees wit wages astbcirsolcc n..aan, Required I tions
will do the work,W destmcturc is nth intcmdeduraRetalfm delSa.TB44.
and profession Code:The Convector's License law does rot apply to an owoer sa
property who build+or improves Merton,and who does such work himself or though
his own employees provided Nm such improvements me not intcMedl or oflneE for
We.If,however.to building m improvement is sold within rose yearofoompledon,do
m
ownbuilder will have to burden of proving Nal ba did not build or improve for Fur-
poe of sale.).
n 1,u mar of the property,am exclusively contracting wit Worried conoacbn to
construct the project(Si 7044,Business and Professions Cade:)M Cntrector.U-
cense law does nm apply m an owner of properly who builds or impmvea detach,roti
who contracts for such projects with a contortions)licensed pursuum in the Conuadors
licenselaw.
❑I nm exempt under Sec. .B 9 P C for din reason
Owner Date /
WORKER'S COMPENSATION DECLARATION O
1 hereby.lf rm ander penalty of perjury one or de fallowing declaretiotu: O
1 have and will maintain a Certificate of Conahuo self-insurt for Worker's Compere
tion.u provided for by Section 3]00 of tc labor Cade,fa to performance Of the
ok for which die pormus is issued.
❑1 have and will maintain Workds Compensation Insurance.as textured by Section
3100 of de L.W,Code,for dm pcnormsnce of to work far which this permit is iaxaed.
yWorker ompcnutim Tho ,mnand Palieynuphsryen2l�1/I
Cartier: k/:Tann✓� Policy No.:_� -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need Out be complerod Base permit is taco hurdrM ddlers(5100)
or las.)
1 certify tout in the performance of the wok for which this permit is issued,l shall
nth employ my person in my mann so as to kohnno xubjw to to Worked Cumpery
satian laws of Callfomla.Data
Applicant
NOTICE TO APPLICANT:IL after making Nis Certificate of Exemption.you should
become object to Ne Workers Compensation mv,iotm,of the labor Code,You it
forthwith comply with such provisions or this permit shall W dared revoked.
CONSTRUCTION LENDING AGENCY
Q 0 Ihereby affrm tat mere is aixisenucdon lenlm,.gertcy for the perfomuna of
z N me work for which this permit n issued(Sac.305),Civ.C.)
leaders Name
(Y } IaMersAddress
t>J I certify dm 1 have mad Ni.application aM are that to above incrustation is
dcorrect,I agree to comply with JI city and county oNinanas and state laws teleting to
.7 Z building con.vuction.and hereby mdonae rtptasenutiva ultra city to enter upon Ne
U O above-mentioned property for inspection purposes.
W F
(We)agree to save,indemnify and kap harmless the City of Cupertino against
U liabilities,judgments.costs am expenses which may in any way accrue against mid City _
} W n consequonce of de granting of to permit.
[� d 'API'LICAN3'UNDERS�ANT. MPLY N'IfH ALT.NONf )INT
U RCE /o00
nature.Applicm Da
HAZARDOUS MATERIALS DISCLOSURE
Wll the applicant or Ban.Wilding occupernr sate or handle harardous material Re-roofs
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the HW d and Safety Type of Roof
Cole,Section 25532(x))
❑Yes ONO
Will the applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
crit haurdaua air contaminants ax defined by to Bay Arca Ah Qaeity Management installed. If a roof is Installed without first obtaining an inspection
°i I agree to remove all new materials for inspection. Applicant
❑Yes ON.
Ih.e mad to hnardwa mormis.romincromms ander Claper695 of do Cali.
understands and will comply with all non point source regulations.
farria Heart&Safety Code.Seetiom 25505.25533 east 25534.1 andexatmd their if Oe
Wilting umen h .tenant,that it is my responsibility m verify de occupant
afde test W tenet arena of a Cerldicaa
0 a Signature of Applicant Date
r one ager ate
All roof coverings to be Class"B"or better
OFFICE