00050012 (2) CITY OF CUPERTINO PERMrr lqo.
'BUILDING DIVISION PERMIT CONTRACTOR INFORMATI N: �� Sib I,�
BUILDING OUR ,,/�` as If L HeR l
hoc DR • k SANITARY NO APPLICATION SUBMITTAL DATE
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L � O ��g Vopfc rn /C CONTROL#
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:CHITECf/ENGIR BULDTNO PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION '
O Z ❑ 1 hereby aPorm the I are licensed ander pmvisiods of Cluipter 9(commencing
Job Description f
m is on iviyp3pglM1eLic.0 eaM fain n ;,
azS� ,omit fmceande cL r(/...1L/1
me a Dow Common,s Co # i
- O Dao Conuspu , ` ���
&O ARCH ECL N ///111
X.
1 rs y am shall w Public s C a
foss,
a =v, OWNER-BUMDER DECLARATION
tz Q I hereby a%ism that I em"amid from Ne Contractors Licewe Law fm the
1'O following reason.(Section 9031.5,Business and Profusions,Cade:Any city m county
m which require a permit an construct,Wmr,improve,demolish,or minor any summon
Priot u.its issuance.Wso aquire,tuapplicant fw,uch pemut m Gleasigtudyampeu Sq. F loor r a ation
that he is licensed pureuanl to the provisions mite Conmxrore License Law(Chapter 9
(commencing with Section]000)of Dilmon 3 ofthe Business and Pmfeuiom CWe)or
tut he is exempt therefrom and the buil fm dm singled i u.Riot Any violation of 3G;4—
not
p Ocupancy pe
Section 7031.5 by any applicant for.pemJuubjm,d,e applice,to a civil pemlry Of — -
nm more then five hundred dollars($50)).
❑1'.. .,.(theproperly,mmyemployaawimw.gwutheir sole,.Nnaaawu. f Required Inspections
will de the work,and Neetmcmm is trot intended moRwed for sye(Ser.]044,Bwiuu
and Profmsiom Code:The Cow there License Law dal nm 1,hi s lf owmr through
a� /
properly who bunds or improves a crcon,and cove does such wwk himself Or Of 1 ' I /UUU} /..,'Lt/vj
his own employers,'midW that such improvements sm not inm.dW m.Rercii for
sale If,how ever,she building w improvement is sold within one year fcomplinhat'the
owneebuldm will have dw burden of proving that he did not build or improve for pm- I� t�Il n h
11s1 au mvary ( +kms ' Il UY V/a� L So
❑1, nen of the Property,am exclusively contracting with bamW conuacmn - v,
(unionconstruct the project apply
]094,Business and Py Win, w CWeO She C°nvutm',and cense Law dasnot applyman owner./progeny cove beddanrientmvw Conmeend ' JUN 0 4 2001
whLace fmauch projmu with a conwemr(s)licensed pursuanno the Canuacmrs
License Lew.
❑Tem exemptundamsm. ,B&PCfm Nisreuon - y� p
Owner Date ��/�16®Bltl'ul '
WORKER'S COMPENSATION DECLARATION
I ureby affirm under penalty of perjury one of Ne following declarations: -
1 have end will maintain a Cmificme of Consom,elf-hoom for Worker,Compem '
don,as providedhhi for by Section 3]00 of Ne Labor Code,for the perfomuna of the (\1,11y1/I�/y�]
k for which this panni,is issued. V
❑1 have and will mamuin Workers Compensation Insuwdce,w requimd by Section � .
MY
Laver Cada,fur Imp.turn athe work for which this pcnnit is iceeuW. �Q ..
My Workers Compensation Insurance wrier end Policy numbv art:
as
Curler: Policy No.: y! - �
CERTIFICATE OF EXEMPTION FROM WORKERS' 4.r
COMPENSATION INSURANCE
(This utti,m neW rant becompletW ifthe PenrW is froom hundred an,3100)
m leas.) -'
Icmif in Nape an eof wotkfor hickJh�e isi dl shall
not i anY pars. in an nn` w .y1neN t°mac a re Compcn- `,
Winn L 1. 0life in
It
Applicant
NOTICE TO CANT: ,Wt r g it a roam of Exemption.you should
No. a coin y i suchWedrs Compensation m this provision,of the deemed
Code,you muss
fwthwiN comply with such Provisions m this Permit shall w domed rmokW.
CONSTRUCTION LENDING AGENCY
0 Q lureby offiran thatthereeac.mmelcul lending agency for the perfomunce of
the wank for which mil permit isLSA ued(Sm.309].CtY C.)
Lenders Name
ai > Lenders Address
W Q 1 unify that I have read the a,],claim and,mm that the above information i, . .
.0.7. z correct.1 agree to comply with all city and county ordinances and state laws misting to
C.) Obuild;.,cimenswuon,and hereby amhmen represenWivu of this citym enter.upon Ore
above-mentionol property for inspection pmparzs.
W r. (We)agree m and save,indemnify keep hmmless to City of Cuporom against
Q f.) liabilities,judgments,cmy and cxpmuv which may in any way accrue egmi,said City -
�W W in consequence of de,granting of this permit.
H C"I APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ,
V Z SOURCE REGULATIONS. - /1
Slifuume of Appl¢anUCmuasor DAo�
HAZARDOUS MATERIALS DISCLOSURE Data
Will the'.,Urmorfuture wilding occupantnom.r handle Wood..,Mo..
rud e-rOOfS
.M defined by the Cupertino Municipal Cale,Chapter 1.11,and o e Health and Safety
Cale,SmOoo 25532(a)P Type of Roof'
❑Yes No "
Will themplicanumfawmbuildingmcupant us egaipmenl or ded.e,whish' All roofs shall be inspected prior to any roofing material being
emitbueM.°•aireanumimnn as definW by the Ar Air Quality Management installed. If a roof is install 'thout first obtaining an inspection
taree to remove al w ater' Is for inspection. Applicant
oma ye . mann rCuprer6 Sof GW;. and d wi e m ly w' h all non poi. sourc regulations.
.is Heal safety odei 05 533 ]5534.II if the
idldmlidws mew mlyh arena yiti my 'esiblirym�at Ne cupan, ot c"m no bah t 'minis. eOf.Cenif�ig c
o rnadm ildagent ,,,,) D = Signature of Applicant Date ,
All roof coverings to be Class"B"or better
OFFICE