00040067 (2)a
BUILDING DIVISION PERMIT vac^air vmivc i=a v).
BUILDING ADDRESS:
O �JNA�ME: / io to /I g_. .
DNI::iJ - Q7 Z'Z'•' L ol(J � Com.: 95d z 3_
'ARCHITECT/ENGINEER - rjap �y
6 k1 -Y L J
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r ❑ v LICENSED CONTRACTOR'S DECLARATION
Z O N 1 hereby affirm that 1 am licensed uMer provisions of Chaper 9 (commencing
onS wiNSation9000) of Division 3 of rhe Business and Pmfeumses Code, and my Banat is
d¢ Y N in full force TanLic.d eRe9�,
0.6 License t `� M _
. W 3 u y Dne_SS DEkr
g O ¢ ..ARCHITELTS T'SDECLA ATI :• .. -
� 1 uwercintl my plans shill be vied u public rcmrds '
0 O , Licensed Professional
0
Oe, 11. aURDER DECLARATION � '
g Q f hereby (Sai rho tem exempts an the Contractors Co s: Any c I. for the
CCC Cay ❑ .following or soa (Section 703 L5, Business and Protectionist diowu Cade: Any city w minty _
i 3 which requues a permit m answer, eller, improve, demolish, are a sig end samrme
priono its issuance; lso rtquirct the applicant for each ucir, to file a signedClatelnentthat '
(error, is ur,wit pnsed unwnuo N) of Divius sion 3 mf Ca ostoars Licen.Lew(ChaWer9
(commencing with herSection rand) of Division 3 tithe aged exe and on. Any.
n .st Code) w
Nat he is 31.5 by
therefrom and the bens for the alleged raemant to a civil olation of
Section , flim by any red dint for a pemtiuubjats Oi eppliunuo a civil penalty of
nor mart Nan five hundred dollars (S500). —
❑ Lo the work, the Pestruc,wmyemptende oilhwagesas their sale 7044,8 utian,
will do fework, and the structure is not intended offered wdoforor plyto an owner
end Proproperty
whorls Cade: The Conoyes ticrors License o does such
nor apply tom owner of
property who builds or improves Merton, pr who does such work himself of through
his own employees, e Provided Nm such improvements thin or. intendedof
offered for
cele.If, howewile buil ding rimpmvemena it sold within oneild car cishavc for the
owner-builderofsawill have rhe burden of proving Nat he did nal build r,imprave tm pm-
❑ 1, u owner m in properly, , Business xdusandvely contracting with licensed rstrac ,s to
Coma La Mees or I$ec,oan,wrofiandorywho antd..ori'DIe CAnbrom, rid
U-
ma Law does or apply to ti owner of property who builds on imraves Naeem and
who convects for such project with a con6actorfq licensed pursuant to the Contmcto
Lt. in Law. " .
[I1 am exempt under Sa. . B &rP C for this reason
Owner Dek
WORKER'S COMPENSATION DECLARATION
1 hereby affirm ands Penalty of Perjury or. of W following decimeters:
I have end will maintain a Certificate of Consent to self-inmm for Worker's Camper.
..tion, as provided for by Section 3100 of me Labor Code, for the perfomsence of the
o'k for which this Permit is issued.
5I have and will maintain Worker's Compensationanc
Insure, m "umed by Section
of Ne Labor Sade,for the prommoano. ofthe work for which this permit is aimed. '
� ��� �' COMPENSATION INSUMNCEV� t
(This.sectim need not be completed ifthe permit is foronely rdrW dollies (4100)
or less.)
I certify Net in theperfamince MNe workfarwhich this Permit is isued.I shall
not employ any .an in any maswei sou I. become subject to the Warren' Compen-
mtion Laws of Califomia. Dek
r Applicant
NOTICE TO APPLICANTi If, after melting Nis Certifies. of ExemMim; you should
hecome mbjat to the Workers Compenssams, fatowi ns of the Labor Code, you must
forthwith comply with such provisions or this Permit thin he darned revoked.
CONSTRUCTION LENDING AGENCY
Q lbunchy affirm Oat there is a construction lending agency for the Performance of
the work for which mis permit u issued (Ser. 3099, Cie Q
F't.ti Lender's Name
((� N IeMer. Address
(.>a 1 certify that I have rted this application and sink that the above Information is
Ca '� comic, l agree to comply with it city and county wdfnences and stare laws cluing in
Z) zf, O •building construction, and hereby ammonia iepksenutives of this city to enter upon the
movcn.rioned Property for inspection Premiums.
W ei. (We) agree m aasa; inti mnify and kap hamdese Ne City of Cupertino against
0 C.1 liabilities,judgments, cosi and expenses which may in any way scaue against said City
�s W in consa9vence of the granting of this peemit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI. NON -POINT,
C.i ti SOURCE. REGITL n/a/
Job Description
' On. d 5L7
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B RDOUS MATERIALS DISCLOSURE
Will the applicantorfumrt Wildingmcupmatmeorhandlehaperdous material Re-roofR
as defined by the Cupertino Municipal Code, Chapter 9.12, end the Headband Safety • s
'Cme,Section 2s532bol - . Type of Roof r
_ ❑Yes
Will he appliran,nrfuture building ncrupant oar muipmem or devices which All roofs shall be inspected prior to any roofing maierial-being _
mitk"" havrdma air commtirini ss defined by the Bay Area Air Quality Management ,installed. If a:roof is installed without first obtaining an inspection
" I agree to remove all new materials for•inspection. Applicant
❑yet �' - � -: , d
Ihave ,<;d the, ha„•dmae m.knals mlmirerieni under LTepter 695 of No Oulu- un erstands and will comply with all non point source regulations.
fwnle Health & Safety Code, Suctions 25505, 25533 and 25530.1 uMvstaM that if the J
building darn �n�g�,�p��1{Iyy�';heveemnank this my rtsponsibility mnoti(y Ne oceupmt� ( !_/ -' / II QV
of Ne roO. _'must.me[ miteuence ofaCmificam mf Occupancy.. ���iffYsl�/AA/
`�: Signature of ApKicant Date
Dwner or hour a „Dae
- - - ; All roof coverings to be Class "B" or'better
'OFFICE