00040005 (2) 1— CITY OF CUPERTINO PERMITNO.
BUILDING nmstoN PERMIT dONTRA TQ IN Og M TI g cb
BUILDING ADDRESS:
620 D G SANITARY NO. AP.L O UBMITTALDATE
OWNER'SNA E. w
O CD /tTL
NIC C NTROL#
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.\RCHII'I:CT/13NGINIiER , ku k4-. BUEUI_G]EERMIT,INI;O
6
z OLICENSED CONTRACTOR'S DECLARATION
O z— 1 hereby affirm that I w lia,ued under provisions o Chamberm
er 9(wmeneing Job Description
ayt: wihS.lkm7000).f D,i' Sof Ne fmw'...sandProfs Code,aWmyliccnae is
xf Liroll fora avd eRal. a � /
Daseve Class_ ^ _con DELL /V/V
{., C CHr1ELTS DECLARATION
1u P shallbemada public becods
al
O ucrosed Rofasmnala
a.w OINNER-BUILDER DECLARATION '
h Z< 1 hereby epi.thsl l am exempt from Ne Contracmfs Licence law for the
C follmving asson,(Salion 7031.5.Buaines and Prof es cos Cade:Any city or manly
w which sequins a permit an catswa,dear,improve,demolish,or repair any structure -
e,3 m sq. Ft.Floor Area ,,f Valu E
priortosliceuance,also sedpormanotto there,Oa appliam for snchpemth mflles Law
r9 .
Out he is lleensed pursuanua me proviaimaorda ContratlMe Licmeal�w(Chapter
Ron
he I,t egurpo Sailrom and th miuon3 ofmlBmioeseaW Po Any vi Cede of APN Number Occupancy•`y e
.IMI he is exempm mertfrom and or beers for the alleged egempnit to Any violation of _ p y p ,
motion TO315 by any dyed dma fm a pemdt anbjau the applicanno a civil penalty of
tGa mom Nen five hundred dollars 153007..
rl.asawrar arme yrapenr.a mr employae wilnw.ger.,weiraale.mnpem,tian, Required Inspection ..
/"EI do Ne work,sW theswaue now ivtcWedmaRemd for We(Sec 7046,Bu[imss
and Professums Coda The Contractor's Liana Law does as apply to an owner of
Properly who builds oe improves thermn,end who does sncb wmic himself or through [ /
his own employees,provided met such improvements are not ineanded a named for r�/L
We.If.however,Ne building or improvement is sod within one yearafampledon,the
ownc,-builder will have the burden of proving Net be did mt build or improve for pun ,.
poseaf.R.). /^
I,u awar of Ne property,am exclusively contracting with licensed contractors to '(/
onmott Its,project(Soc.7040,Bmlncss and Professions"10 The Cormoos U.
whoc,machewdos retapply1.jets ithaofpmaperty who Wildaorimpaves mereve.sus -
wlrocomau, for such projects withs2onriicmr(s)Iicensd pursued to the Conuwtota 1
License taw.
' ❑lame rA BRPCf Nis
Owner � Dae � a
WORKER'SCOMPENSATIONDECLARATION
1 mbyafRmunderpenahyafprsjury ofdtefolimingdeclmdomi
(have erred willmainw..0 fiamufcon ttoself-insuaforwoAees Compere t - -
tion,as provided for by Section 3]00 of the Labor Cadc,for the pertowance of the
wo,k for which this l" his issued..
❑1 hoer ami will maintain Werkces Compensaion Insurance,s required by Section
3700 ofthe labor Cale,for the performance ofthe work for which this permit u issued. '
My W'arke/[Compewtion Insurance terrier am l Policy number art:
Cartier: - Policy No.: -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seatoo maednm be completed ifthe pmmit is farveehursdoeI dollars(SUM) ,
or less.) -
I cenify But in the performance of Ne work for which this permit is issued,],bell
not employ my person in my manoer so'a to become aobject tome Worker'Compcn- ,
smibn Lawsof C.1amem Date '
Applicant
NOTICE TO APPLICANT:IL afar malting this Cedificaa of Exemptive,you should
become subject to me workers Compensation pmvisime,of the Labor Code.you must -
formwim comply with such previsions os miss permit shall be deemed evoked.
CONSTRUCTION LENDING AGENCY
Q I hereby affirm that then,iaa consumedon lending agency for the perfomnm of
the work for which this permit is issued(See.3097,Ci,C.)
E. LacMees Name -
�, finders AdcreF[
W 1 certify that 1 have read mice eppliatum and sac ilut me above infomation is
d emrat.l agree to comply with all city and county ordinances and state laws mesting to '
U 0
build ingcon.tuction,and hereby au0mn.epreatnativm the
es of this city to ease,up
above-mentioned property for inspection purposes.
W E. (We)agree m save,indemnify and keep hsmles the City of Cupertino against
Q U Iuhiliuea,jWgmunrimcosts sed cxpensea which any in any way am me against said City
} W in consequence of t a granting of this pamie- -
'[� In APPLICANT UNDERSTANDS AND WILL COMPLY WI'I'II ALL NON-MINT
SOURCE REGULATIONS. t
Sigmwre ppllcan ontmaor Data
RDOUS MATERIALS DISCLOSURE '
Will the applicant or future Wilding occupant store or handle hazardous material Re-roofs - s "
as defined by the Cupertino Municipal Code.Chapter 9.12.erd the Halm and Safety
Coda Stenon 25532(e)7 Type of Roof .. ,.
' ❑yes P�a I.,
Will the applicant or future,building occupant uee equipment or deviceswhich All roofs shall be inspected prior to any roofing material being
5th..doaaaircomaminantsaadefined bythe Bay ArcaAriwalityM»gewnt installed. If a roof is installed without first obtaining an inspection,
I a ree to remove all new materialg for inspection. Applicant
❑Vas Na � 1 g
Ih.ve mad the h:uNoua wtadal. ` par 695 of da Cali-
as
understands and will,com 1 with all non point source regulations.
ryuire e,maunderCita .. P Y P g
Tomas Health Sefeysquabs,Sections 2SM5.25333 and 25536.1 underkand that if the
Wildl gdoes cu tYY vx ertnanL muni 1rtsponsibiliry to naifY led ceeupant
fmcswl c metpnart n neo Cmifice of panty. '
=Lj Signature of.Applicant Date
ner yp
/Data
All roof coverings to be Class,B"or better
OFFICE