00080135 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO. -
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GWNER'S NAME: - AI'i'LICAI'IONSUB IIAI'E
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IONS: SANITARY NO. CONTROL NO.
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ARCH)FECT/ENGINEER: BUILDING PERMIT INFO -
�m' BLDG ELECT PLUMR MECH
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LICENSED CONIRAMOR'S DECLARATION
G5 = In«en Iran that I am licensed ander f Chapter 9(commencin Job Description
�_0 Y a provisions o p g
E,m e u will S ll for eland ofect. on 3 of The❑u,inc„and Prolirsiun,Gull.and Toy beano A
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is full farce and liens. J�/�,� r 'H•y?�L /A/
y a
License Cl... Lic.a /
al,U Do Contractor
a LL a.t; ARCHITECT'S DECLARATION
j 1 T le,l ndlmy plonS Shall tw u,ad a,public records
w C O 0O Liccn,cd Precoi,imul
c.n o� OWNER-BUII.DISR DECLARATION
1 hereby affirm that 1 am t,man,from the Couraaor'S License Law for the
C < following a'mun.ISCCGnT,9031.5,liminos and Profcwion,CaM:Any chy ar county
C o which inquire,ii porton w constrom almr,improve,demolish,or m air any,toucan
L 3 er pr t t t :. also y the ppl' t f h Permit t rd signed statement
Thai he I,licer,dp , the pimlimoor, itn Carl." Larose 1 (chplatr S Ft. Floor Area Valuation
(or exempt to Sect Wool The'. t fto B Ji f Calc) LI' to
or d Ib ,h t d II b for me alleged exemption.Any violeuo1 r�
of Sectione than
by any applicant flora pcnnn snnjacis Thu appbrun 111.1 civil luywhy
Broad more man E.e hundred dollars as(w), APN Number Occ ancy Type'
❑Las owner or the propt.,my cmpinyeen with wages as meir.aole mmpenwtinn, 30
— ,/,377
will Aa the work,and the arvcmre i.Bol intended or ofmom Ii,r sale(Sec. N..
Easiness and Profession.,Code:'Thu Connector's Liecnrc Low does ton apply to an t Required Iflspections
caner of property Who builds or improves thereon,and who does such work himself '
or Through his own enoployea, provided that sach impmvcmems am not inrendW
offered for da,If,however,the building or improsemem is sold wilhin one year of .,
completion,the owma,larilder will have the burden of proving that he did not build or ��
ins mr pammc of,ale,).
r of The proryrty,am exclusively contracting with licensed romractun to
construct the protect(See.7(94,Busmen and Prnfewimry Calc:)The CareactnLr
License Law does not apply to an owner of pmpeny who build,or improve,daemon, OCT f2 1 2002
and who,comract for such pn,jccm with a connucions)licensed pursuer,to the
Contractor ,teem,l.a, ,,��/'�
❑Iame or arder5ac. ��ss ��H PC foflhi.rens,) - BUILDING
Q �/1r0� 1' ftCiI
WORKER'S CON 1'LNSATION ULCL AVON T
I horcby affirm under penally of perjury one of the following declarations:
1 hove and will meinmin or Cenilieme of Consent To self-inson for Wader's
ConTpcnsafon, it, provided Toa by Section 3700 of The Labor Code, for the
Per sinner c oldie work for which his permit is issued,
Cl I have and will maintain Worker's Conopeasmian Insurance,as treated by Section
37W of the labor Code,for,he perfamearce of,he work for which ibis per,nir i,
Lsacd.Aly Workers YC-o-mpensation Insurance carrier and Policy number arc:
Coni �L Poor,Nil'IIc>o ins D I
CHRTI14CAT10N Op nxEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This section fired n I he mmpinul if Thu pen til is pli one hundred dollars
SI 00)or less.)
I,citify that in the performance of The work for which This permit is issued,I
Shull not employ any pecan in any manner so as to become abject to the Woder.• '
Campeosmio t Law,of California.Dam
Applicant
NII IICE'10 APPIJCAN'1'.IL after making mi.Certificate of Esemplam.you should . .
hemmc,iol coa m The u
Walker,Compnatinn provonof d
isis the Lay Gala,you allot
C lbnhwhh comply with such provisions or this permit shall M deemed revoked.
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F` ^ CONSTRUCTION LENDING AGENCor
' 1 hereby aft!an that them is a construction lending agency for the performance
W nf,he work for which This l<ry}y gyred(Sec.3P)].Civ.C.)
Lender's Name_/l�lL4aC
z Lumdcr'I Add—, -
V i,coaly Thai 1 have road thin application and,tate that obuve information is
ii E., c^rtecr I agrco To nnnply suit[,nil lily and comfy oMTnarce,andmade Tawe relining
�) to building construction.and hereby authorize repownm,ivcs of this city to enter ,upon -
y s the ahovcmeraioncd pwpeny fur inspec,inn purposes.
1.., a (We)agree 1.case.indemnify and keep ham,le,da,City of Ca,ninoagnin.a
VW liabilities.judgments,costs and expenses which may in any way Same against said
z City in co sequence ofm'granTlnp of bio Penni,
APPLI UNDERSTAND N CQ�IPLY W ALL NON-POINT O
RE uLA'no 1 J &/,7�� ' Issued by ' Date /
Tg
lure to App sanUcan,m<lar ''Dal Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE
Will the apprcanlor'future building ocspan,.line orhandle for...darmedaf Type of Roof'
to,defined by The CupeNno Municipal Code,Chapter 9.12,and the Health and Safety
Cole.Section 25532(a)'I
❑Ye, 7�1Nn All roofs shall be inspected prior to any roofing material being installed.
wnom,..,u<anTnrrodprebui`aadby benByAe.AirQulityMara,swh... Ifa roof is installed without first obtaining an inspection, 1 agree to remove
to h Will the air<omuminanor , 1 Bed by the Ray Ana Air Quality devices
einem �' p s g
insert all new materials for inspection. Applicant understands and will comply with
I Nr all non-point source regulations.
have mad the by Coca.Scene.,25505,25533
nq,25533ta under Chapter Ess of be .
filmhaiailealm&Safetye 1,jime a lscoode25533and,purcilundecaand That
ifthebuilding tinesnotment,ly hoveatenon,,shat it is I re.poce'or:Dh,notify the
rxeupnm of,he¢quirements which mus,be ma c n o-r rcmanee of:T Cenifieme o[
Occupal
/I d Signature of Applicant - Date
,,orA to aamnn.e neem - /��. All roof coverings to be Class ,.B,, or better
OFFICE /