00050065 (2) CITY OF CUPERTINO PERMITNO.• /
eun.DINGDIVISION PERMIT CONTRACTOR INFORMATION: `Od0S-0��5
Ell
ILDING ADORES : /gyp a/M ,')/ ``
O � �L/J !/Y//r� �Uf/J]�//f. I/y�t j) //��`/// r['// SANITARYNO. APPLICATIONSURMITTAL DATE
NEMS ME: G // V ��//�/'(N• �"
N/C CONTROLM
LONE: .y09ySyf
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RCt11TECl'/ENGINEER BULD[NC PERMIT I IN3
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7 LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that I un licensed under provisions of Chapter 9(commencing _ Job Description
cg.mi with Soclion V00(I)OHN iion7ot,(t1he Busmmiand Proleniab Code,aMrrylicaueit' ^�J �// //� n /�,Y/
j2u Lienee rw and eRect. 11/lkk�yfl�J Lic.N .. /j/L nIaz 4 em,#11
b- Date e S D1CL vt, YY,Y e /
O.� Ad shelf use DECLARATa N
i understand my plans sM1ill be used as Public reuNv
Y0p
Id<ensed Profeuiond
�_m OWNER-BUR,DER DECLARATION -
> f hereby.frim that rem exempt from Ne fe.i.tar s License Law far the
6
' ❑ following reason.(cation 7031.5,Bminus and Rofessiow Code:Any city a munry - r
which requva a permit ou emntmm,alter.improve,demolish,or repur any acture
a m Sq: FL Floor Area Valya io}
Prior to its issuance,also requires the applicant for each Permit mfile asigned statement
Netheis ingws pumumtr'0d)provisionsof Ne eBusi u d mlaw sCh )9
(ret he is ixemit thect1on70nddre Diasis frofthc Busiassmdon.An ionsCnde)m ApN Numbs Occupancy Type
that o i%exempt therefmm and the buffs for the alleged exemption.Any violation of „J r • P Y YP
Section then
five
anyapplicantfor apeat%abjecuthe applicant .civil pelWty of
not more than f ft hundred Lollan y employees
L as owner of the property.re my employee.with verges a their role7W,Business Required Inspections
will do lesions Code: he Cotefanm intended or offLaw
red does net apply to an Owner
of „
and Professions b Code:The eves therio,and w Ido does nes apply himself lf owner gh
properly who build.or improves thereon,and who dao a rte work dedoror coed for
his own employeese provided that such improvements are not intended a offered far ,
sales If.however,the building or improvement is veld within one year completion,the ,
ownerbudc.) will have the burden of proving Nat he did not build m improve for pury s
poommet tho I
El 1,as ooar of the property,am exclusively contracting with licensed emanations an
conatrod me projml(See.7044,Busowner
of uM Professions Code:)The Convector',Li-
c rue law dues not applyje ts owner of property who sed p or imaa.ee theteon,and / I
who contracts fa such projects with a contncmKq licensed pursuant Contractor's
License Law.
�tart exempt underSa. ,B&PCfor this reason O '
nor Date
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under penalty of perjury me of the following daluatiom:
(have and will immu in a Certificate of Consent to ml6inmm for Worker's Compsm- -
etion,as provided fa by Section 37M of the Labor Code,for the probrouane,Of the
h for which this permit is issued.
I have am will mei tion Wohei s Compensation Inauntme,as required by Swim
Of the labor Code,for me Perfannmu of the work for which this Permitislamed.
C Go, s�pit� u��ll summa canner and Policy
�..wi ,[� tr/ Policy NO,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section r ead nm be completed if Ne p eorm is for oa hundred doll ar e(SIM)
or less.) -
Icenify that in the,Performance ofine wink for which this perout is issued,I shall .
not employ any person in my manner m as to M1eume subject to the Worms'Compri-
section laws of California.Dam.
Applicant .
NOTICE TO APPLICANT.IL after making this Certif ate of Exemption.you should
hemute subject to me Workers Compensation provisions of the Labor Code,you moat
forthwith comply with such Provisions or this permit ahall W dimmed revoked.
CONSTRUCTION LENDING AGENCY
Q I hereby afrmNet them is....merlon lending agency for the perfmmmce of
rZ.. the wink for which Nis permit is issued(Sec.3097.Civ,C.)
lender's Nume
a 7 Lmder`,Addmse
{resI certify mut 1 have read this application and ewe thin above
the fulmination is
C. z consul.I after to comply with all city and county ordinances and%rate laws relating to
J O building convection,and hereby iutho e,repruenwives of this city to enter upon the '
above-mentioned Property for inspection purposes.
:L Fy (We)agree in me.indemnify and kap homeless the City of Cupertino against -
� V Whilides,judgments,costs and exteriors which may in my way acme against said City -
!p�. L4: in consequence of the granting of this pm ulr
P D"� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT
(..) z SOURCE REGULATIONS. t
Signature ofplicantlCon cmr /� -
HAZA OUS MATERIALS DISCLOSURE _
Will be r future Wilding ucupant store or handle hazardous material Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12,arta the Health and Safety '
Cede,Section 25532fayl - Type of Roof
0Y. -11.
Will the aPPlicam or(mure building Occupant use equipment or devices which All roofs shall be inspected prior to'any roofing material being
mit barardous air conwninme to defined by the Be,Amu Air Quality Mmegemenl installed. If a roof is installed without first obtaining an inspection
Dismc,? ' I a ree to remove all new materials for inspection. Applicant .
E]yes No
Iheve radtW hazmdme materials requimmenu under Chapter 6.95 of the Cali- un erstands and will comply with all non point so/ttt,,ttiree regulations.
fomite Health&Safmy Code,Saxons 25505,25533 and 25534.1 uMentund that if mea 5 .^/1 0
building docs noicunemly have a mount,that is is my ruls0mibllity m minty the acupmt J
of me expel menu h must W me�prior to issuance of a Ceni&at f cunow
SignatureApplicant Date
OWnCr OrO OIIEWB [ ale •
All roof coverings to be Class`B"or better
OFFICE