00020157 (2) CITY OF CUPERTINOp'.^ PERMITNO. ,
BUILDING DR'tstON PERMIT CONTRACTOR INFORMATION: i'-0o' "ab �5 '
BUILDINGADDRESS: i'�r
g•'ss {�1v ^, r- s SANITARY NO. APPLICATIONSUUBBBMITTALDATE
WNERSNAME: ` / 3 - �
N/C ,. CONTROL#
El
ARCHITECT/ENGI EEII f BULD1N01'RRMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
OZ.NN-.p ` t hereby from that I am licensed neer provisions of Chapter 9(commencing „ job Description
t•4CSW wiNS .M.6.7000)afDivisic.Iof Ne Buenas and!Profeuwm Cade.aM my license is ^ 't.
yN in Wnforce andeRect - / /_ ,.v �AI / I
z a hears rceClasss Lia# s- IMI'/. `'/•;r '
O t• Dak Contra,um - t
�iIii0 ..
C Li O¢� " sshallARCHITECTSusDECLARATION }
5 1 undemund my,Plans shall be used-Public records T1 I-,,)
Cir _ bq�i_ ✓\
Cleansed PmfeaionJ
Re,I am
DECLARATION - 3
etZ G 1 hereby aBhW Nn[sin esemPt from the fi Contraction License Law for the
d ❑ whichfrifirsit g invit. (Section 7 menu m sine,.tad ow., nimn Code:Any city nt county
3 which rcgdma a promo re eommhe Jke improve,demolish,or eea signed aeamuie S.' FL.FIOOr Area - ,Valuation
prior wits issuenec,Ja mquircs the applicant fmsuch pend W file a sigmdaukmmt q'• -
Netheislicen�edpumnnuoNeproviritimof the ContraWYs License law(Chepkr9 - LJ OQ fO , .
that
he
ingwiNSectlonm andth Di onfr ofd se Buain-mWPmfnsiam Cede)m APiif���iii Number OCcu ane e
cut he is attempt therefrom and the b-is car the alleged exemption.Any viokuon of •) ' P y�P
Semlon 7031.5 by any applicant for a pemdi subjects the applicant to a civil penalty of I/
pr mNan five hundred dollars($500). - -
om'I.asowWrarNemapmty,mmyempltiyeeawiNw;j-nNeNebierompen-titin, Required Inspections'-'
cods do Ne work end Neetiucwrc is rktimm�eedotoffercdfor sale(See.7014,eusinen' I' ' -
and Pmfessiom Codes:.Tbe Contractors License Law does not apply to'm ower of
property who builds or improves thereon,art who conn such weak himself or through
his own employe-,Provided On such Impmvern es arc not intended or offered for
We.If.however-the Wilding or improvement is sold within one yrs of completion,the
owmpWildcs will have the burden of proving that he did but Wild in improve for pur--
❑ 1,as owner of the property am exclusively cono-ening with licensed contractors W '
construct Ne project(Sec 7010,Business and Profanities Code)The Contractors Li.
.. _ _ '
cepa Law does not apply to an owner of propmy who builds c Improves thereon,and
wheocom ms for such p.jecu with a ciamemb r(J licensed pursuant W Ne Contractors -
❑lamev<mplunder .Sec. 'B&Pcfiodasommm
Owner
WORKER'SCOMPENSATIONDECLARATION
1 hcmb alfrm under Jt of r on of the following declaration:
Y Finally Pe JmS g
I have and will maintains Cenificim,,consent to self-irtanrefm Workers Compen-
'.moon,at Provided for by Section 3700 of the Labor Code,for the peA'omunce of tiff - - -
work for which this permit is issued
❑I have and will maintain Workers Compensation Imuran,,to mgored by Section
3700.Ohe lsbm Coda,fm the perfarmsme of the work for which Nin permit is round. -
My WorkerY Corhpenution Insurance center and Policy number aR::. ' - -
„ Gmiec Policy No.:
{ CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE r
(Thissktinn need not becomPleied ifthe permit is foronehmdreddmlen($100)
I cenify Ne in theperfurmmceofthewmk forwhich Nis pemtit is rued l shJl� -
6 not employ my No.in any manner so as to become subject to the Workers'Compen-
rmionlswnofcidifomiiiDak -•
'Applicant .. - ,
NOTICE TO APPLICANT If,after making this Certificate of Exemption you should
hecomc subject to ted Worker's Compensation provisions of the labor Cade,you most - r
fonhwiN comply with tach provisions m Nis pesmiuhell bedeemed revoked. -
CONSTRUCTION LENDING AGENCY, ^ '•
Q Q IWmby affirm that Nem is acontmction lending agency for Ne kdomwceof ,
7u r
the work for which thin permit is issued(Sm.3097,Civ,C,)
IsMers Name .. .
a, Larder Addrcra .. .
W-0 1 cert fy out I have read Nu'eppliution and awe that the above information is
P. correct I g m'imply wed JI city sod county adinnons and auk how"relating to , . . ., t.'' - }•
U O buildingcomuuction.andhereby outhodarcpreamltiv-of Nis city taemerupan Ne
^shove-memianed property.for inspection purpaai. ,
pit Py, (We) S.W save.indemnify and keep hmmless Ne City of Cupertino against _
liablhu-,ludgmems,crate and expenaa which may in any way,act.against said City -
>y W in conagnnce of the granting of this permit. ° -
[� 0. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Y -
fn SOURCE.REGULATIONS.
SignamrcofAPPlicantKU.mactm- - Case
HAZARDOUS MATERIALS DISCLOSURE -
-
Willdkapplicemorfair.Wilding occupamemaorhandle hazmdous material Re-roofs
.-defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety -
Code,Section 25532(o7 • Type of Roof
❑yes [I No
Wild, :ppiiaanlo�fatnre Wilding o<daP,,,tale<guipment o,d.„eai.vhich All roofs shall be inspected prior to any roofing material being'
lhmardous aircomromarts as defined bynhe Bay Arca Air Quality Management installed:,If'a roof is installed'withoutfirst'obtaining an inspection
isni"' ' - I a tee to remove,all new materials for inspection. Applicant..:
Yes' ❑No, g
Ihave,-d Ne ha.;,arrddaaa makdale'scgnirtmenta soder�hsger 693 of Ne Lbli •understands and will comply'with all non point source regulations.
fomie Health&Safely Cede:Sections 15505,25533 and 25530.1 milmsund that if the „
building does nm currently have a terunk that it is my responsibility to notify the occupant
,. of the requhcmenti which..in W mat pdorm ufinme of a Cenificak of occupanry.
Signature of Applicant Date
(45witer or m&!ed agant Date t -
';;;,, - All roof coverings to be Class"B"or better '
'OFFICE