00040161 (2) CITY OF.CUPERTINO - - ( PERMEENO.
e°f UIL DNO DIVISION ERM CONTRAC ®H IN'EOg RIMAT(hO+ N: V V� I / _ I
.L3ck\ ()•l VisCQ I, SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER N h r: /J M NP 'k
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lis % El
WC CONTROLp
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AfI1TECT/E GINEER .\ iuIDIRG;PERMIT'lINFO
t-N LICENSED CONTRACTOR'S DECLARATION
a Z�0 I he., aRme
Het 1 asn licensed under provlsiom of Chapter 9(commencing Job Description
P=C� wiH Sarice TdeffecDivision3ofthe Bu.ine,sand Profeveiom Cade.and myli«nu is 1 1 /1
in full tame sus effect. h �^t� ,�/.�( •{t„LL�J, I /�,1�_l'Ixadp,
OdO License Clea Lic.N I `" "♦a.� ` '�V� y♦9yj•�\� ALA
0y Dne DECLARATION
uJ 0 J ARC all heaved
e DECLARATION F
j, I understand my plans shell be used u public rccorde _
p0
e>1 R 13cemed Pmfealorol OWNER-BUILDER DECLARATION
t a i hneby afimt that I am exempt from she Cemeteries License law fm the
qfallowing rtamn.(Sation'l031.5.Business,and Professions Coda:Any city or county
3 which rcquiies a permit m construct,alter,improve,demolish,or repair any structures. $qFtF'�OOr Area - ValUat10I1,
pricrto its issuance,alsote9unts the applicant for such permit n file a signed alternate, , .alternate, TT
that he is,licensed pursuant n Ne pmvisims of the Comoros Licmu law fCWpn 9 V
(commencing wish Section 1(1001 at Division 3 ofthe Business and RvfasimaCndelor
that he is rump,therefrom and the basis for the alleged exemption Any violation of AN Number _ I Occupancy Type
Section 1031.5 by my applicant for a pemut,ibject,He applicsuuo a civil pmahy of
not mom Nan five hundred dollen($500).
1,as..of da,popery,or mycmplaya.with w.ges as their nlccompematims � � —Required Inspections
willdo Ne work.and the mVcture is not intended or ofered for We IS..10fa;Busima
and Profasdons Cade:The Contractor's Liana Law docs ns,apply to an owner of
property who build,or improve.rhimm.,and who doe,such work himself or through
his awn employ"',p nvidW improvementssur an,such sant imnded or ofe.ed for -
tile.IL haweaar.da,Wildingmr impmvemem is•old withinmse yonrofcone leber,the `
owarbuiMn will Have Ne burden of proving that he did net build or improve for pir-
pmeo(ale.).
I,u owner of Ne property,am exclusively contracting with licensed conhacmn to
construct an. ct the project(Sec.loan,positions and ProfesaCode)The CoThe Contrunr.Li-
me law does not apply to m ownu of propmy who builds or improves Hereon,and
whoconuauforsuchprojecawiN a croura s)lken.N prumt to the connector.
❑1 am xemp under .B k P C for His a reason
w
Data
WORKEEREsCOMPRNS ONDF.CLARSGGN -
I hereby aRm under penalty of perlory cos of He following declarations:
IheveandwillmeinteinaCcrtifcne ofcomenua slf-insure for Workeh Compen- \/
tion,as provided for by Section 3100 of the Labor Code,for the performance of the I -
ak for which thla pencil,is issued.
have and will maintain deducts Compenorion Insurance.as required by Station
3'ADif He bar Cnk,for He rfomenceof He work fo which Hia permit u imued. _
My W., Ca nation In ran curter end Policy '
Carrier Policy No: '^
CERTIFlCATB OF EXEMPTION FRO NEW R -"
- COMPENSATION INSURANCE
(This section deed ns,becompluedfthe permit is fmone hundred ddlus(SI00)
or let .)
I<mify that in the performance of the.,k for which this perm,is issued,l shall - ,•
not employ any person in any mannNm as to baccon.w.bject to the Wodscre Camper- ..
ration Laws of California.Data '
Applicant ,
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should -
became subject to the Wo.krrs Compensation provisions of the Labor Cada,you must
forthwith comply wit such provisions or this permit shell be deemed revoked.
z CONSTRUCTION LENDING AGENCY - ♦-4
z I hereby affirm that Hes is v conrmcdon lending agency for the perfmnun«of
z C4the work for which this partissueddl is issued(Sec.3W7,Civ.C.) '
F Landers Name „
ai > ItMer'x Address - . -
W 0 I certify Hat I have mad We applicadoe and sea that the above information is '
z sonar.I agree to comply widt NI city and caumy suditunea and state laws relating n
building cooemetion,aW hereby amboriu reprc.smarives of this city to soar,upon the
above.mentioned property for inspection pmpous.
W `r '(We)egice b.ave,indemnify and kap ha.mless the City of Cd,mm,.gaimt
V Eabiliabs.judgmens,caa andapcnaa whi,h,.y in my way.,meegalm,said City - +
�. W in consecutive of Os goomm,of Nis it -
i 0. .. UNDF.RSI'AND. AND ILI :OMPLY WITH ALL NON-POINT
V S URGE RE ILATI NS.
of pp icon n or te 0/9
'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building acupsm au ,or handle It rmaarud Re-roofs '
as defined by the Copeman Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(,)1 - Type of Rbof ,
❑Yes
Will the applicant or future building acupam rax".I'me.,.,devices which All roofs shall be inspected prior to any roofing material being
emit hvardous air conumin.nu as dented by thwBay Arca Ar Quality Management installed'. If a roof is installed without first obtatning an-inspection '
�, / I a ree to remove a w'materials for inspection. Applicant
❑Yes
l Lava mad the hlvrdou.mmnal.rgairemenu under Chasscr 6.95 of the Cali- un ods a wi c mply with all,non point source regulations.
fame Health&1S Safety Cade,Seniors 2 SD and 2553..I and ed dot ��� '
of c.nor1. have nam, nit ony."nsibility ton ifY IM _
of c rtyarc ns, m m r r arve of a Certifir I f
cror son n se.la,s n are
Signature of Applicant Date
All roof coverings to be Class"B"or better
OFFICE