0030050 (2) CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: D 0 O s�
� BUILDING ADDRESS: 1 f e
es/Jrp 01 /L /��//�P� /.,{g///t/� , SANITARY NO. APPLICATION SUBMITTAL DATE
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RCHITECf/ENGINEER �j�' /J3' //{/2 Bu1.DfNO rrRnnT INFO
au�
F.? LICENSED COMRACTOR'S DECLARATION
1 hereby oRmr Net 1 am licensed under provisions of chapter 9(commercing Job Description
k•HF� whh Sionnie]I%I(I)afDivision 3ofdm BusiwoaaW Rofmions Codc,Wmyli �
c U in onf«ce and<Rut. /J[� J ,{ /tom j�
C u License C s Li,.M L• lee at/a 7 �U GLH/O/, / d
3 a H Datu��Con DECL �l [(ii(�w LL(!� / s1/
I_u;C g ARCHITECTS use DECLARATION
1 understand my plana shall be used as public records
1E0o
LicensedDofmiow
_^ OWNER-BUBADECLARATION
m ARAnON
i—
t-Z 6 1 hereby.(Sere IMI 1 an exempt(sure ON Contractors License Law for e
❑ following reason(Section]031 S,Builnns and Professions Code:Any city«county
A
which rtquues a Permit in ConsWct.eller.imitative,demolish.in repair any structure
S Ft. Floor Area V I tion
t1calhosl muanrearmain India thovisioumf«such permit Licks signedstatementkl'
that M is licensed P.mmnt mNe provisions 3 the Contractors License Lew(Chapter 9 U
Icst he I.xempttSection andtf basis
theta BuxiwoxeWon.An,mu Cade)« APN Number Occupancy Type
IMI he is cu11Wl therefrom W the basis(«the alleged exemption.An,violation of P Y YP
Section 7031.5 by any ri,lims for.item n aut ere applicant to a civil penalty of 2
pret moTan
hfive hundred dollars(5500). r/
I.mmnernftheprop<ny,«myemploy«swilhwageanlheiraolecompensaum, Required Inspections
will do the work,and dNatructure is not intended uroRemA(«sale(Sm,7044.Business
and Professimu Code:The Coavacmri Liam raw dors No apply to an owner of
Property who builds«improves Merton,W who d«a such woak himself or through
his own employees,Provided Nm such improvements art act intended or oRertd for
cele.If,base"".the Wilding or ImPI9Ye..is sold within a«ymatcomplosms,doe ,
owner-builder will have the burden of proving that he did nm Wild or improve for M-
poseofiale.).
11 1,as own«of dbe property,am exclusively conuxung with licensed mnmeton to
construct she project(See.7M4,Business and Professions Code:)The Convector's Li-
ce«e,law does MI apply to mown«of props ty wed Wilda or ion mvea thtteon.and
wed contracts for auch ponjosto wish acommetWs)licensed Pursuant m the Convectors
License law.
0 nd «
exempt Sa. .BAPC In, ruaaan
Owner
Dau
WORKER'S COMPENSATION DECLARATION /
1 heneby.Ran undo penalty of perjury .t of Uro following worket tiau:
1 My<er o will maintain a..3700 of he Lai mCode.for
forWorkersCompen-
pro h thi(«by S<cuon 3]Op of the 4Wr Code,f«Ne perfonaume of Ne
or which this maintain
is issued.
1 M1aveLawill ode.for ,perfoa Compensation work
for whihas rtquimdby Section
3](IOof he Labor Code,for Ne performance of drc wart for which tris pcnmit is issued. i"1
My Worke�i tion ins ynm.bd Polic,i:M6yO�J
V
Cama: Policy No.: L/` CK �G��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action wood eta becomplevd lithe permit is foronehundod MI m(SIM)
or Ion.)
1 certify IMI in the pedorro.of IN work for which this permit is isi I shall
Not employ any person in any..am w a.o moo.subject to the Workers'Compen-
suit.Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subjeet to the WorMur'a Compensation provisions of the Labor Code.you must
forthwith comply with such provisions ar this permit shall W rimmed revoked.
CONSTRUCTION LENDING AGENCY
I hereby aff rimthere is O comtmeuon lendingage«y for
the performance of
Z the work for which this permit is issued(Sec.3097,Civ.C.)
t.. Lemurs Name
[� 7 leaders Address
1 unify that 1 have reed No application and same that the above infomution is
caw «nei l agree su comply with all city W county bedroom.W sura laws reeding to
U 0 mildin,mrsstrucuon,and timby authudurepresenwives oflhis city m emerupon IN
above-mentioned property for inspection purposes.
fss E., (We)agree to save.Indemnify W keep hamilm the City of Cupenirw against
0 V lublliues,judgmems,muca and expenses which may in any way amme against said City
'. W in consequence of the granting of this permit.
[� APPLICANT URDE ANDS AND WILT.COMPLY WITH At.[.NON MINT
V z SOURCE R17 6f1 NS.
— 229/vD —t/s
Signature W Apr isc Inctor one,
ROOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store in handle hansolms material Re- oo
to domed by the Cupertino M`uniNo I Cade.Chapter 9.12.W the Health and Safety
Code,Semon M32 I❑ Type 6f Roof
❑Yes
Will the aMlicam«future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hladous air contecom nu as fined by the Bay Area Au Quality Management installed. If a roof is Installed without first obtaining an inspection
"" C a I agree to remove all new materials for inspection. Applicant
❑Yes No
Ihave reedthe M,da .14"1 recluementatimttCTapter695oftheCai- understands and Till comply with all non point source regulations.
forma HealthA Safety Cols.Savona 25505,M533 and 25534.1 unW that if if the
Wildingdocsna cutrci lyhaveae"l,rMtltismyresponsibilitymnaifylM aupanl
of the rtyuucmmy w met psi«m usua«e oI.Cr irr r a
P �/ Signature of ant Date
Owner of author etc
All roof coverings to be Class`B"or better
OFFICE