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00050023 (2) CITY OF CUPERTINO . ' PERMIT NO.• ,_BUILDINGDIVISION 'PERMIT w/ 0� 00.2'`Z) . BUILDINGADDRESS:,/� • OW :.S h /.,fa S�' 'r��jGq�,��• . L/Uf' . .//./(V//)✓/:S,. (*NJ/1�LLV/dG iK/' VV�//�(/t//A!�{ } •. . i SANITARY NO. ON SUBMITTAL DATE �D/ PA0n NIC CONTROLN. HONE ' VX /7Lt .� ARCHITECT/ENGINEER - B114D TP ILMI in • ne o :. �/��, Z O 7 3 LICENSED CONTRACTORS DECLARATION „ ` O z p I hereby aRrm that I licensed under provisions of chapter 9 Rommern ng , ,Job Description' with Satron 7000)ofDi n3 f Bust saint Rofaeiom Cmde,aM mYlicentt . m full force and nRect ��rc< �t<aeGla�—�e. �7io EXi/s�frrN�w� AS/�NA/ Ly SN/N/ Q 3 i h Dem ?/lelz/1L•L Conwcwr �� . y/�Y(//45L/s J p_ ����/H�r f/ JH' �Ci/G-'�✓ H OG ARCHITECTS DECI,ARA N I undue my piensshall beccdas upublic ret i g o Limiand Professional - " ,' '/��0�1'/J M'FC>IZ I!U $7/j Ll./}-!/G/V Sigi .' u7 OWNER-BUILDER m CLARATION w^ ��XU w ,�' gZ 4 1 hereby ePomh that 1 am exempt from the Contractor's Licence Law for the + 'V( 'V NFO following return (Section 7031.5,Business and pernmaiom Code:Any city or county - m 3 w which rtyuucs a Permit w construct,alar,improve,demolish,or repwr uni.mwmre prior to its issue"",also rcrc gms Npermit e applicant for such peit w file a signed statement Sq,,Ft. Floor Area p'Val�upation Nrs at he is licensed puuau no the provisions of Ne Commutes Lt...Lew(Chapter9 " - •60 ' (commcncingwlNS<cuon7000)of Dlvisbn3of Ne Buvnasmd Piofe ions CMe)w ppN N bar that he I¢exerni therefrom and the W ii for me alleged exemption.A,violauan of Occupancy Jype. Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of _ r y w not more Nan Bve hundred dollars("Oh, - ❑'I;as owner ofm<Pmpeny,or my employees with wages ere their vole compemNan� '. ,Required ln5 C ' ns will do the work.sndthe immune i-mor imeimed or offered for Mile(S.,7044,Businesses , . I Bofned.Code:The Com mi License law does not apply to an owner a '• properly who builds of improver Vumon,and who does such wart,himself or tluough•, J\ - his we employers,provided tut such improvements are not intended or offered For' .•J/ f sate If,lumsever,the building or improvement is sold within one yesrof romplwon,the - - o builder will have theburden of prov g that h bu❑d not Id or mprove for per ' 3 •. W. f s ). - , ! " r_ i� ❑1 r f Oa awmP pertY armuclusivelymentracting with licensed contractors to omuva di mcimt(Sec 7W4 Busman and Profesoom Code)The Comrectors W cense Law does nut apply to m owner of property who builds or improves thereon,and - who convects for such projects with acontracwda)licensed pursuant o the COntmcmer, License law. - - ^ ❑I sum exempt under Sec. ,B&P C forthis lemon' owner Data WORKER'S COMPENSATION DECLARATION 1 hereby aPorm under penalty of perjury one of the followin6 deduauom: - . F1 have and will maintaina Certific...fcomenuo self-ini far Worker's Compen. rv, nation,as provided for by Section 37M of me Laboi Code,(ser the perfomence of the 'E Is,for which this permit in issued. 1 have acid will maintain Worker's Commute Imureme,m required by Section '+ the Labor Code,for the Rmlonmem,of the.,it for which this/permit is issued. MY WWork Caylst_'l�iq�l/ran9�ggsDR epCP,g,aY num VU ..r 'l /'rkY//Ard/(9p CERTIFICATE OF EXEMPTION FROM COMPENSATION INSURANCE This section need not W completed lithe permit is foronehunmed dollars($100) or less.) I certify mat in the performance often work for which this penial is based,l shall - nor employ my person in any manner so as to become subjecno the Workers'Clangs, . intimi Laws of California.Dam• " Applicam .a. NOTICE TO APPLICANT:IL afar making this Certificate of Beemptim,you should become subject to the Workers Compensation Provision.of Ne Labor Code,you must '• + . forthwith comply with such provisions a this Permit shall W deemed invoked: •s ,. CONSTRUCTION LENDING AGENCY t C) I hereby grim thea them is a construction lending agency for the Performance of . ti •Re work for which this permit is issued(Sec.3097,Civ,C.) " Under'.Name l' Landers Address fi7. Q I I benify tha I have rand Ric`application and sets met the above information is G4 correct I agree to comply with all city and county ommuncee and sem laws relating to - si� .0 Obov building comuumon,and hereby authonu representatives of this city to enter upon Re - - b„ ae-memloned property far inspection purposes, .. la'Fait (We)agree to ave,indemnify and king harmleir the City of Cupertino against QUO Iiebiliva,jWgmems,<me and expenua which mr,hany wayamme,seassid City Pin constraint.of Re ,and.,of this permit. rn APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT - • - a .V z SOURCEREGULATI S S gmmrc OfA VC u to " Dam HA4 A US MATERIALS DISCLOSURE Wtimes or fur building occupant storeorliandlehazardousmanurial Re-rOOfs " m ticCned by the Cupertt o Municipal Cada Chapter 912,and the Health soul safety CodType;of Roof it. t - a Sectmn23532(e)T v E]We I)dNo' • '1 -JI1 •All roofs-s wise the Ecros or Tamm Wilding eco' hall be inspected' TlOr t0 an r0 PP g pant use<qui mem or devices which roofing material bei. emit hurandous'air contaminants a defined by the Bay Arca qv Quality Man.gement, installed.;If a roof is Istalled without first obtaining an inspection Dlsalnl ' �/ - ^ ❑Yea �t1hNo } W I agree to}rerriove.all new-materials for inspection: Applicant •I''I understands and'will comply with all non point'source regulations. I ha a rad she haardoue materials req 'ramentsunder Cheger 695 of the CJi- f mu H<alth&'Safety Cade Swiom 25505 25533 and 25534.1 and trod Ru if the - -building does nacumnty hue amnam.that itid myiesponstbtlirywnotify the cupmt of the mput hich st pin m issmrce of a Cen rtsgtgrof Ly/y (/" Signature of A Ilton owner or authonzed t '--�— g pp )' Date 'o s, All roof coverings to be Class."B"or better fOFFICE