00040151 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: Vbn 4 L/ '
BUILDING ADUHFSS: r, /� I ��fr� /� ry
O Inn V/tGtQr`/`C y/iyr l/J f1 \ $ANI"1'ARY NO. APPLICATIO SUBMITTAT
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OWNS ,S NAME: t _
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/NGIN V BULDIN01'ERhIIT INFO
AHCHITECf/ENOINEER ��0e) ?qS`1
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z O H= 1 LICENSED CONTRACTOR'S DECLARATION
O _ 1 Wmby affirm than 1 sUnder m licensed uer previonow of Chapter (rommencing Job Description
F,
4Z, 0w wish Scctwn700B)ofDivision3ofwe Busineasad Rafe ima Cee mylimnseis
to fall to.and often.
ace a,< Liceme Clan Inc.#
OaU
Date nv«tw #
i u 0 3 ARC} E S DCpCL TION / w1 ,
N I ani t I C erected.
ii¢c /
ttn Pmf<aeimai
r-z y OWNER-HUH-DER rcptfir rn Me RATION
r z a 1 bertby.(Sita that 1 am exempt from the ContuctCos Licenu Law for the
E F a following aeon:(Salton 7 031.5 Builms m,Raf&=Ji Code:Any city n s wunry
i. $ which regaum a permit re construct,after,improv.de permit
m repair ed antemrt
5_ pnimtoits iaauence.JaomquirtatheappEnntfonucApetmitmEleasigtedau¢mem Sq. Ft. Floor Area � Valuations J
Map he is licensed pmauant to Ne provisions of Me Cmtrecmes License Lew(Chapter 9
hnmmcnemg wiNSemfonl(1p0)mDivieimt3nrme Bn.inma ens Pmre.a;mr.Code)Us APN Number Occupancy type
than he b eacmpi M_form end arc Buis for the alleged caemption.Any violation of �i e+P Y YP
S«tim 7031.5 by my apphifor a permit mbjau tM applicmt m e civil petWty of
pof mom thin Eve handrail dollars(SM.
1,an ownm nrthe progeny,nr my emvinym with w.ga ar weir ante enmpematim. Required Inspections
will dothc work adthcmunurt is not intended uroRmd fm We(Sec.TMC.Business
and Professions Code:The Conammor's License law dim war apply to an owner of
pmpcny who Wilda or improves thereon,anal who does such wart himself or through
his own employ.,p,Uoo d that such improvements art nal intended or oRcred for
ale.If,however,the building or impmvemem is sold within one year of completion,Me
nor-builala will have we Wden of paving that he did not build or improve for pur-
pou of sole.).
I. f owner of we progeny,ann"elusively connecting with licensed cmtranon m
ivmauct the project(Sao.TNG.Buainna and Profeuimu Code:)The Convectors Li- /
ccmc law don not apply to an owner of property what Wilds or improves dinner,and
who conmets for each p--P4with•contmetor()Licensed pauumt M Me Contractors O
License law. Q
❑lameaempru .B k PCtoojjj/tttM1M1M1ii�ee�rts/n�mi
Optic ,,Ur0 Ll
ORIUi S COMPENSATION DECLARATION _
1 hereby>Rrm ander Penalty of perjury.'of the following decleratiom:
I I hive and will maintain•Comileane of Consent at soft-haute fm Worke.Compen-
tion,as Provided for by Sectim 37M of the labor Code,for the penfomunm of the
.it for which this permit is rsvaed.
1 Wve and will maintain Workers Compensation Imaimce,in retainedby Section
3700of the U Wr Code,fm the nolf rma
ee of the work for which this permit in brad.
My Workers Compensation Insurance carrier and Policy number art:
Carries Policy No.:
CERTIFICATE OF EXEMPr10N FROM WORKERS'
COMPENSATION INSURANCE
(This swim nnedmt becomplatd ifthe permit is Intone Wished dollars($100)
a 1<u.1
I m�1yft1m ,.fdb,),4fir ,toMeWloonsCppsmwt employ o be{rlubiat w the Wohen'Compen-
sotion TataP7f
APPIia'mt -
NDHCE APPLD AM':IL ahcr meting thio Ccnillcane of Eacmptim,you should
become subject in the Workers Compensation Previsions of the Labor Cde,you must
forthwith comply with each provisions m this permit Mdl be dnemeri revoked.
CONSTRUCTION LENDING ENCY
ZIbecebyvlhtm Nett rt-visem don ppptg ages9pfor the perfomunm of
Z
the work(m which this s (Sec -v
Lenders Name
y# 7 1<ders AddresJ y
r� I certify t I hive reed t is eppl;cation end elate wet we tbove infomuttion s
Prcmmn.I.,me to comply with dl city ow county ordinances and num laws masne to
D z Wiklm"onstmcaoq•nd Wrobytoolwris mptnrnwives of this city to enter,upon the
C.7 trove-mentiond progeny for inspection purposes,
Gas F„ (We)Agree to save.;demndy and keep harmless the city of CU,,"mo against
Q V liehilltin,judgments.cow,-W-xpOpA which may in my way.ceme,gainst aid City
} GL =7=101
cmaequenee Of the ng of spctmn.
► Pr APPLICANT UNI .I' N ANU WILT P WITH ALL NO rlgl Nl'
U Z. soulecr:REf
igv of ApphcenUCmmUtU, Date
HAZARDOUS MATERIAIS DISCLOSIBIE
Will them'la.or future Wilding occupant snort or handle h,ralloue mand,l Re-roofs
in deEnud by the CuKmno Municipal Cade,Chaeta 9.12,and thc H W th W Safety Type of Roof
Code.Section 25532(07 YP
❑Yes GPS
Will Me applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hawarta,.;annum;nmu fod by the Bay Area Air easily Management installed. If a roof is Installed without first obtaining an inspection
"etl
❑Yes No
I agree to remove all new materials for inspection. Applicant
❑
I ba"road the and tcquinmen 95of Mc C01- un erstands and will comply with all non point source regulations.
fl
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xaw a s,ryy «tie sox,3s . a zss3 tante wa it we
11 1: a'
eta fn, vee ,in s apo mmtifylhc also,of the mgWm m yms e tp r mifcauof c
n n / Signature of Applicant Date
to W agent It
All roof coverings to be Class"B"or better
OFFICE