00040162 (2) CITY OF CUPERTINO Se
- PERMITNO.
BUILDING DIVISION PERMIT, CON RA ; �l\'I. TIO "� �� ,
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BUILD INO ADDRESS: 11 - -
C-7 .�S oo I��^ /I II ./. .. SANITARY NO. PPLICATION SUBMfITAL DATE
OWNE 'SN / J M�V(.( w r //
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NIC CONTRDL#
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LICENSED CONTRACIORS'DECLARATION
z 1 hareb,tiffirm that 1 surn licensed under Provisions of Chapter 9(mmrm seg Job Description _
FK,
N N2 - naeade.eM my license is
andeRect.
yL"cense Ce LM
C60 C7,
lo", amConnecm
t- O •.ARCHITECTS DECLARATION .
1 understand my plans shell be used es Public rmoso e " -
oo
ae UrensW Professional q ,
_I all OWNER-BUILDER DECLARATION -
C Z�< 1 hereby affirm that 1 am exempt from the Contractor's License Law for the -
f,F m fallowing ro sen.(Section 7031.5,Business and Pmfnsiom Code:Any city or money
which requires a Permit m construct,eller,improve,demolish,m repair any swcture
s_ Sq. Ft. F.loorArea Valuation
Into to its issuance,also requires the applicant for such permit to file a signed statement - 1 O
` Nethe is licensed purauanuo the pmovisionsof the Contractors License Law(Chapter 9 - r
(commencing wish Same. of Division 3 of tha Buemess and Profnsmoe Code)or - PN NUI11bEr ecu •1�� .
Nat he is exempt therefrom and tlBanbasis for the alleged exemptiaa Any violation of /u,• pant y T,I pe
Section 7031.5 by any applieane fare Femur mbjects the applicanno a civil perulty of
rot more Nan five hundred dollar(ISM). -
„{' ❑I,as own.o(Ne property.or my employee wish wages ex Heir sale compensetlon`, - Required Inspections `
will dothe work,mal the swemrc is not intended or oHereE for aide(Sm.7044.Business -
ead Profeasinm Cade:The Cunuam n,License Law does am apply to an owner of
pmpany who bull&oryirtipoves dseneon,and who does such work himself m through "
his own employe.,pmvidcd that such improvement,are nm imendd or offered for
We.If,however the,building or improvement is sold within one yeuof completion,due
owner-Wilder will have the burden of proving that be did not build on improve for per-
yoj�ofmleJ�
p�1,as owner of the property,am exclusively contacting with licensed contractors to
w t the patient(See 0044,Business and Profess onx Cod )The C n anus la-
' ten Le Joe noupply ro an ow.m.f,rapeny who buildx P .drtrcon rod. -
wh m tred f inch projects with a conaemoist licensed pursuant, ri Conwctees
License Law
lame pt,n&,Sjt.
Gwner Dem
WOR SCOMPENSATIONDECLARATION
1 hereby eMrm an m perulry of perjury moeof the following declared. -
❑unso andwill rtuintain aC dificate ofComenuo self-inmm for Worker's Compen- -
orlon,ns Provided RoF by Section 37W of the Labor Cade,for the performance of the
work for which this permit is rend.
Lhave and will maintain Wnrkcrs Compensation Insurance,as reputed by Section
3700 of the Labor Cde,far On perlonnance of the work for which this permit is issued.
My Workers Compensation Insurance canis and Pollry number arc:
Carrier, policy No.: •`. -
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE r
(This sec don need rad be co rpletedifthc permit is forms hundred dollars(SIM)
m less.) --
I certify that in the performance of the walk for which this permit is issued,I shun
ers
ant employ say pon in any ma rte au/ 6gne pfa15m th Worker'Compen-
APPlicmi .;
NOTICE TO APP :If,ef�ies plioris CdRtme�Exemption, .yshould
become subject y Workers Compeer this provisions of Ne Labor Coke,you mon -'
fonhwiN comply wish such provisions or this permit obeli be domed revoked.
CONSTRUCTION LENDING AGENCY
' I hereby affirm Nat there is em.tmcuon lading agency for the performance of
Ne work four which this permit is issued(Sec.3097,Civ.C.)
F.y Lender.Name
Q! > Lenders Acidness
I certify that I have read this application and state that the above information is '-
emrem.l agree to comply with all city and county ordinances end are¢laws relating to ,
.� Z building construct., it hereby authorise representatives of tastily to enter upon the '
V 0 above-mentiond pmpany her inspection pu,sura "
W E. (We)agree m save,indemnify and keep huml.s the City of Cupertino against
-� C.) liabilities,judgmants,c...ad expenses which may in say way accrea.,tunnaaid City
} Y m cnncequenee of the granting of this permit
E_ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-MINT
V. SOURCE REGULATIONS.
Signet um of APPlicaDue ./%•Lam / �iC"//' ✓ s/ /g-•'(I '/ /
_
HAZARDOUSDISCLOSURE. .
MATERIALS DISCLOSURE 1
Willy t e Cuportor fuutm building e,Chapter
r 9.12,handle Hawlilous mamtisl Re-roofs -
" C defined by the Cupertino Municipal Code,Chapter 9.12,end the Health eiW Safety s -
cede,smdbn 25532ror. //// Type of Roof • - " "
❑Yes ll No � - . ,.• '
Will the applicant orfutureWilding occupnt use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hazWouesir camaminanta as defined by the Bay Arca Am Quelity Management installed. If a.roof is Installed without first obtaining an inspection
Yu
I agree to 'remove'all new materials for inspection. Applicant
❑ -+ No ; d
Ihave'naad Nn hicardm,materale mgaimme�ts ander Chapterli.95 of she Cab-un erstands and will comply with all non point source regulations:
Rome Health A,Safety Code,"am T5505,25533 and 25534.1 udmsud that if the e -
building does not current yhese eternmet it is my responsibility m notify the minister,
ofthersixm whit andortowiti mof.Cenif am f eour'say.
.Signaiureof Applicant Date'
Owner N nz age
All roof coverings to be Class"B"or better -
OFFICE