00040090 (2) CITY OF CUPERTINO PERSHING,
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: Obb I,�hQ n
6UILDINC AIJDRF;55: V"( V-CV
/`� y N ,a _R )_ _ /1 Tei( � F- `\ _ / ( (�/��/ 1�� 1 SANITARY NO. APPLICATION SUBMITTAL DATE
.
OWNI?K'S NA41P_ /V L7 K�jUl •%.'/V/'•`S/J ^_"\IAJAQ.b-t t—V In IL
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CHITECT/ENGINEER C&S-b) 5-0 O BIJLDING PERMIT INFO
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F.. y LICENSED CONTRACT'OR'S DECLARATION
o= I hcmby aRnn Ines 1 em licensed uncle provisions of Chapter 9(commencing Job Description
a,=Cm with Sation 9000) fDi i on3ot Ne Business end Proteuions/C�od/e), dmylianssis
< in can force and effe`I. v s•
License e s Lic.N 7� Com scon 30" y�y
w 3 u t" Dme ARCHITECTS DECLARATION ` ���
IC`OgrI undersrand my plans shall be used as public retools
cc
as o° u«naed rloreaam.a �--
='c, OWNER-BUILDER DECLARATION
Z a I hereby a@nn that I am exempt from the Comm,tor's License Law for she
M following ressen.(Semon 7031.5,Bminas and Profeuions CWe:Any city or warty
which requires a q.I,to c..c,,alter,improve,demolish,or repair any structure
a q. Ft Floor Area I Valuation
prior m its issuance,also inquires the applicam f«each permit w Nae signedstatementsmcnt UU
Not he in licensed pursuant to the provismns of Ne Contractors license Law IChepter
(commencing with Section 7")of Division 3 ofthe Basi nes sand Pref itimaa for
that he is exempt therefrom and the basis for me alleged exempsisn. v mm of // y ..{V umbey, \ Occupaancy Type
Section 1031.56 limen for famed thea lice eci '1 elf (p J(/ aa CJ
Y any 00). J PP vt Pen y
nos more Nen five hundred dollars($5001.
❑1,as owner of the property,oris employees wdhw an their sole compen don, Required Ins Ions
will do Rte wodi.mid Ne sttncmrcis mtinrcndcde exed tsnale(Sa.9044,8 mess
and Professions Code:The Contractor's Lice law does not apply to an own of
property who builds or improves thereto, d who tl«s such work nimaelf onlwu
his own employees,provided that sucM1Improvement,are nm intended or offered far
isle.If,however the Wilding or improvement is sold within one yearof completion,rhe
Wilder will have the burden of proving that he did not Wild or improve for pa,
pouofsele.).
1,v awncr of the property,am exclusively convecting with licensed contrazsoss U.
C .tinct the es has appl(Seey
to an ownBuser
of and ty who professions builds
i The Convector's Lid
cense Law does r such
je an awncr of property who builds nr ant 1.he thereon.std
whocontactsUsti for such projau with a contracmr(s)licensed pursuant m the Converrors
License Law.
❑lam exemplunder Sec. ,B&PCfor Nis mason
Owner Date !!! �4z
WORKER'S COMPENSATION DPLLARATION
1 hereby aRrm under penalty of perjury ens of Ne following de ram's n: v O
31
1 have and will maintain Section
37Certificate Consent to a Labor Code,sore for Wsrker'e Compnhe
tion,as provided for by Section 3900 of the Labor Code,for the perfommnce of she
for which Nis tme is issued
Z. ointment
.
have and will aintain Workers Co ce of the
Insurance,h his Per by Section
3900 of the labor Cotler,for Rrcpedonnan«of d work for
pw,pheich�rNgis permit is isx�u)cd.
Camas a Tcnetian In prencapah'Policy No.Y1t�-brl&a[�y--f
CER IFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
( d.,eclis,need not has complcsed ifthe permit is forsne hundred dollere(SIOO)
or Ia.)
I certify Nm in she performance ofthe work for which this Motion is issued,I shall
not employ any person in any menser an as to become subject o Ire Workers'Compen-
sation Law.of eel,(.....Dine
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
hao,se subjem m the Workers Compensation provisions of Ne Labor Came,you moat
fonnwith comply with such provision or this perrid shall W deemed revoked.
Z CONSTRUCTION LENDING AGENCY
0 Q I hcrcbythi that Nile isaeanmmetilen ding agency far the perfortnan«sf ' /, I D
the work for whichich permit this is issued(Se30c.309],Ci¢Q)
>
Lenders Name I�
(� j IinderAadres
I APR 13 2000
Pm Q certifyre
that 1 neve ad Nis application and arose that the above information is
0. conal.l agree c comply with all dy and county ordinances and sum laws relining e
Vr�7 z ofinve-pumthuaclion.end hereby aoNonurcgesenusives of this city to enter upon the
above-mentioned d,save for inspection laspnee.
W (We)agree I,save,indemnify end keep harmlean Ne City of Cupertino against By_
V VAPPI
irics,j sRof s,cssmandof this eswhich may in any way accme againsuaitl City By,-
income
•,,,,—_��•__
'. otetitlW gmntin6 pf Nisperit.
NT UNIJERSTANOS AND WILL COMPIY WITH ALL NON-POINTREGULTIONS.fApplicandConvacmr Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicam or future Wilding rccupimarmcor handle hazardous manned Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sana.25532(x)9 Type of Roof
❑Yes tk"Nm
Will Nc applicant or future building occupant the equipment or devices which All roofs shall be inspected prior to any roofing material being
Iha N t,minsms.,deftncdbythe Bay Are.Air QmmlyMunagement installed. If a roof is Installed without first obtaining an inspection
"'c" �
❑ Nree I a to remove all new materials for inspection. Applicant
eml ver read the hazaNw.mamrials regalmmcros ander Chapter 6.95 of the Cali- U d will mply with all non point source regulations.
food.Heald,&Safely Code,Sections 25505,25533 and 25534.I orders und!Nat if the
building does not currently have eten ant.Nat it is my rcsponibilitymnotify Ne occupant
of the s t metpdonoiuoance ofae�MeuMOcey�^
Sign. ure of Applicant Date
Owner uthoreW agent One
All roof coverings to be Class"B"or better
OFFICE