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00030061 (2) CITYBUILDING orvESS1i6NND PERMIT PERMIT CONTeRAC1'Og R I'� IORi ASTIOO 003 ©Q. In BUILDING ADDRCSS: SANITARY NO, APPLICATION SUBMITTAL DATE OWNER'SNAMf' /G N/C /�CONTROLp IGNy OP 3.05¢5 7 2 ARCHIITTEC' NGINL+R - + - +BULUI�OII;fiRMI'I'gl.�Q E° I- z LICENSED CONTRACTOR S DECLARATION 0 Z I hereby affirm 0w I w licrrevnd under provisions of Chapter 9(commencing Job Description ,-,HCw with Section 7")"Division 3ofdw Business and Profusion.Cedeand my license is , y S�:,j in full force anal effect MU Ilceme Clan - Lic.1 H Date Convector, . 11ti Gassed uEP bARArK�± 1 undernW reItem.ha11 / p-w� �{//Th -o-71 i en Licse Pmfesal mal , aw /\ OWNER-BUILDER DECLARATION ' F-Z>' 1 hereby.Rion that I am exempt from the Contractor'.License low for the z o following..lSectime V31.5.Buimss W Prefeui.m Code:Any city m cuumy i which requires a Permit he construct,ager,improve,demolish..,repair any swctwc S F[. Floor Area - Valuation primo.its issuance,alm requires me applicant foo.wh peanut m fileaslgnWagemem /n q' �•�ar met he is licensed pursuant to the provisions of the Connncioh License Law(Chapter 9 22 J (commencing with Section]000)of Division 3 of the But.end Prefeuiou Code)m Sapo that he in exempt therefrom end the basis for me alleged exemption.Any Ywhaon of _ APN Number Occupancy Type . Section 70313 by any applicant for a purest subject&the applicant to a civil penalty9f m more men five hundred dollen(5500). G6 i I,as owner of the property,or mY.repoyma win wage.0 meir..le cmnpen,wan, Required Inspections' will do me work,and me awnure I...,mun ded conflicted for sale(Sec.7W,Bmieevs W Profusions Cade:T7u Comnetoi v License Law does rot apply to we cover of hpropertyis own who built or impmvu Ihsuch i pr who coca web work deed o f of through his own employ..,provided Ihu such imom is W na are no intends a offered for ole If,bower wdl h building.,Inedmpoaevis u a r hewithin...itWild or campWiog me owme-buildtt will have me buNen of provin8 mat he did not bird a impress for per. 1.a owner of project SeopertY�uB exclusivelynd convecting with licensed contractors U.con a me e..1 (See.Toad,Business and Professions Code:)The Contractors and - c Lew dao ror.pply beanwntt.(property who Wild.or imposes tbereomW who c.tinue's for such Mi..win acormencefs)license ..or to the Canvnclm's License Law. - - - IamexcrosunderSec/ B&PSC for rtthis srrele.n 41 Owner f. ✓ = Dao iT _— t �a/. WORKER'S COMPENSATION DECIARATION - - i hereby afford under penalty of perjury one of me following declarations: - 1 have and will maintain a Certificate ofCounu he elf-invert for workeetCompen- smicn.as provided fee by Section 3700 of the Labor Code,for the perfomars.of the - h for which this permit is issued.+' ❑1 hove W will maintain Wakcrs Compensation Intim.,as required by Section 3700ofthe labor Code,forme pc9cro mor ofine work for which this permit is issued. I. My.Worker's Compensation Insurance carrier and Policy number ate: - Cartier: s Policy No.: _ CERTIFICATE OF EXEMPTION FROM WORKERS' - COMMISSATION INSURANCE c ('ibis sectinnnad not becompleond ifine permit is(coon hunme dnllers(5100) - - or recast „ 1 certify than in the perf.mam.of me wmk for which mix Penn is issued,I shall ' no employ any person in any manlier so as to become subject to me Wohen'Common- StImnlowsofCaRfomia.Date to - , Applicant NOTICE TO APPLICANT:[father making this Canificate of Emmpicn.you should become subject on the Wodusex Compen{adwi provisions of me Labor Code,you must ' fonhwim comply with such provisions or this permltshsll be domed revoke. - - CONSIRUC ION LENDING AGENCY- z 0.I hereby affirm that men is construction lending agency for the performance of - Z = me work for which this permit is issued(Sec.3097,Civ.C.) undoes Name V a, 7 Lendeh Address W EI certify owed I have owthis application and sate that the above iMomation is , Z correct.l agoa to comply withell city W county on imncea W awe laws reining 1. building codwourim,W hereby sudmria represonutivesof Ibis city w c...upon me C.7 0 above-otemione property for i .purposes. + - (We)agree m save,indemnify and kap harmles.to City of Cupertino against 0 U habilmon,judgments,coca W expenses which may in any way seems,against mid City } W in conxqunce of da green.,of this permit. r Q APPLICANTONDERSTANUSAND WI 1.COMPLY WITH ALL NON-POINT V z SOURCERI' TIONS.. - c� � 3 Sigew nrt pplicandConGa.Dao HAZARDOUS , US MATERIALS DISCLOSURE Ds Will hepplicanor future building occuanoanem Ismas e hauNou{mearisl Re-roofs - _ u define by the Cupertino Manic' el Code,Chapter 9.12,end the Health anal Safety " 'Code,section 25532(.)^ /" Type of Roof ' ❑Ytr o Will.the applican,o,future building occupant use egnipnen,•m devicre which, All roofs shall be inspected prior to any roofing material being mithamsdoualrcontemirant& wfumdbymeBsyAxmAirQmIkyManagmwm installed. If a roof is Installed without first obtaining an inspection trieR I agree to remove all new materials for inspection. Applicant ❑Yes N. Ihave read mcbsommnW hap,er 6.93of the Cali- understands and will comply with all non point source regulations.' L mnrementaaMerc P Y P g Lana Health&Snfmy c ,setvou 25505,25531 W 25530.I unh,ttood dw if me laukhogdouna haveeteunL ma,io is mY rupensibilitymnaifY meBmpanl ofineraryi us,be met prior he issuance of a Certificate of Oceypem� GG Signature of Applicant Date Owen moriz .gem Dace _ » All roof coverings to be Class"B"or better OFFICE