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00050002 (2)CITY OF CUPERTINO • R IN 5 'Mf1 I L PERMIT No. - :nUILmNCDIVISION PERMIT `.`' %' 00 / 000 BUIIIIyyyING D RPS f /��(.}./�_ is• �i/fJ]I SANITARY NO. APPLICATION SUBMITTAL DATE OWNER'S A F.'' �/NI/_,V V N/C CONTROL q. O ❑ RCHITHCUENGINEER '8 ❑ 4 I ¢P,'RMIT,I. Z� t- y Z .LICENSED CONTRACTOR'S DECLARATION f Job Deseripdon ' og ; s I hereby a m that I am licensed under provisions o(L spur 9 (comes rowing 'vena S1 -.w- with Section 7000) of Division 3 ofthe Busies and Prof asioi Cillo, and m is e arta"fie /.(y/��/(�, {�///�Iy,mfu'�' �" �s+e"l/, // .�� . I,Iccea C Lich I7 • vI.'"'_'•- 3 Dene— Comsat o. y D'/� 1 /l /_lam' F. �/ f 3y U10P TION 1 understand my plans mail as public ., a'n O `- ' WcensWPloficonmad wOWNER Y RATI frDECLAATION - ; 1 hereby a/liw N t 1 exempt empr from he Commences License, Law frothe _• / /y Ofollowing notion. (Section 7031 .5, Business art Professions Code Any city u wanly V 4' Sq- [�[, IDDr ACCs . Valuation i 3 which req res a Permit to consuract, alar, improve, demoliN repo any awcture s ra,dco mature, theapphcam for such pemdtl file signed mtement prior to dwan ••ll d pumano the provisions of l e Contractors License Law (C7upur9 Nn he is licenusu O. v V . (commencing with Section 7000)of Diviiam3'.fthe Bottom. and Professions Cede)m A arose Occupancy Type Out he is exempt therefrom art the besis for Ne alleged exemption. Any violation a p Y `J I) Seedon 7031.5 by any applicant fora permit subjects the applicant ... ivil penalty o! 9 - - of mom then five hundrt4 dollen (5500). / p I, as Owner ofthc property, or my employee¢ with wages as their sole compevadon, - , , R quired Inspections r will de Newark, and the structure is not mended or offered for sale (Ser. 7(114, Buiiuu and Pmfenkrus Coda: The Conwcror's Littnee law door not apply to son owner of -+ ' property who builds cr improves thereon. nal who does such work himself or through his own employes, provided that such improvements sen not intended m offered for t side: If, however, the building or improvement it wild withiumm yen Ofcompletien, the • - ner-Wilder will have the burden of proving that he did not build or improve for pur- , - • - you of sale.). T. . . 1. u owner of the property, em exclusively convecting with licensed contractors to " conswct the project (Sec, 704q Business end Rofesdona CO10 The Co..[.'. Li-' cense Law doss not apply to an owner of property who builds or improves dmrcon, andwho mormacts for such ptojmts with aconwmons) licensed punuanuo the COmnetes. License t Law. _ ^A ' •1 a Ism exempt under Sec, .B&PCforthisrcsson Owner " Data !� . t WORKER'S COMPENSATION DECLARATION - 1 hcrehy atfirm under penalty ofperjury rose of the following declwtioia: - " O I have art will nainidn a Certificate of Consent ulf-insu , for Worker's Compen- ation, as provided for by Secden 3700 of the Labor Code, for Ne performance of Ne - -cr or w which this pewit is issued have and will nttinuin Worker's Compensation Insunncn, m required by Section - - J700of Ne Libm Code, for the performanceO chin work forwhich this pewit is issued. my Worker$^—C canis end Pelle n ` Crainne ` ] .OM1 ari/1 Policy NbY CERTBTC INPROM WOR S' - COMPENSATION INSURANCE - (This ucrinn need her be comPl<rcdifthe permit is talon¢ huMmd dollars (SIM) or less.) Iceni(Y llulin the perfawanttdfthewmkforwhich thiapewit is iieved.l shill .. - , notcmploYa.ypaao in manner soa ve `uh'alZeWorkerr'COmpum- antion lawso e' te.D r1y�5� ', Alip" t •c aNOTICE TO APPLICA : IL ar making this CWTicl a of Exemption. You should - - become wbjed to the Winker a Compensation provisions or die Labor Code; In ..in forthwith comply with such provisions or this pewll shall be domed revoked. u CONSTRUCTION LENDING AGENCY Q O (hereby arm thin Nereis a comstmetion lending agency for the perfomuntt of Ne work for which this pewit is timed (Sec. 3097, Civ. C.) Lenders Name E.4 Landers Address �( I cartlfy thou I he. reed this application and ¢Iia that the ahs. information Is W „• • • . ' 0. z correct. I agree to comply with all city and county ordinances and sure laws relating to hrriu entativesOm f this city enter upon Ne building concdon, and hereby ammpro - atiova•memiswoned property to, inspection purposes. W res (We) agree to aave, indemnify and keep hawlew the City of Cupertino against '• 01,'habilitiea,judgments,mods rot expenses which may in my way same against said City W m cnomgtimm of a granting of this pewit: •. _ 0+ APPL .ANTD ERSa'ANDS AND WILIICOMPLY WITH ALL NON POINT S( IF tEG CATIONS ON r .. /!/ . r • —.D� reof Applicam"co m,law Once ' HAZARDOUSMATERIAIS DISCLOSURE Re -roofs , - .. 7i/QEly1 C �/j Type of Roof J� - Will dramplicent our mina baiIdi meant ¢tort our handle hanatot, reaterial as defined by the Cupertino Munici Oda Chapter 9.12, sed the Health and Sdety Com, Section 2ss32(an ❑Yes .:,. F ` Ang Will the future gatempentr,eeamiPmenirrdevineswhich emishazallous w contaminants a fined by the Bay Area Air Quality Management All roofs shall be inspected prior to any roofing, material being' installed. If aYoof is installed without first obtaining an inspection °'¢tr"'7 ❑Yea No I a ree to remove all, new materials -for inspection.,. Applicant • un ers Ods and will'comply with all non point source regulations. , f Ihavrcadthe azerdouetvsrialemquimmmauMerChapa6.9SofthcGli- -forma Heal Safer e, Seedoni 25505, 25533 and 25531. I understand that if the hue ingdoo¢ Ica nil evcaunem,thmit is my usponsibilitymnmify the- upmit of see IS ich SI O(a Cenifi fact ercv.•.1 ' s ignature Applicant Date O n rar utllon a D u , All roof coverings to be Class "B" or better OFFICE