00040116 (2) OF
CITY
r BUILDNG DIVISION CONTRACTOR INFORMATION: PERMrrNo.
PERMIT Q c} � ' I
BUILDING AUDR655: l0
SANI'I'AkY NO. APPLICATION SUBMITTAL DATE
OWNS 'S NA'!II:` .\ �t\4� �4� y
NIC CONTROLM
CN.. clp� -gam )-99'4
El
,RCHITF,C IHNGINVER IULDING PERMIT INFO
O0O
"u
H>j LICENSED CONTRACIOR'S DECLARATION
z c h_ I nemnr aRrm dont I a,n u.mwd under poirniem.I Chapter 9 aemmen<ina (� Job Description l
rz^u9 wiOh u.7()(0)of Divirmx3-softbe BurnersM 1'saimo Ca}q�e�myhoomeis
z z< in full(aatt and<RecV'a 1 / P V
wee uccmaaass ` dicta
3 s.F Dem J-� "-b� Cmuccwr
LL o 5 ARCH TEC S DECLARATION
f 1 unciennad my Plans shall W used as public meads
i a Licdud W Pre"ancr
OWNER-BUB.DER DECLARATION
I-z a 1 boodby of0rm Nal 1 am exam,.from IN Contracmrs Licanw U.for the
z C following reason.(!faction 7031.5.Business seal Pofm+ims Code:Any city in county
w-2 which.equmai•permit re connote" w.improve.demolish,or repair any shunuro
3_
prim toits isawnce.aw residues she applinnt for such Permit m rile a signed sutemmt ��_ SSI.FL Floor Area VValuaatilig
Nat he is.thenad peruantw the poisonous of the Co..,&.License Uw(Chapd 9 `rJ
Nimmcncing with Section]000)of Division 3.fthe Buttoner and Profncions Cod.)or APN Number Occupancy
Out he is exempt therefrom and Else d e basis for the allegeumption.Any violation of O P Y Type
Seeu.n 7031.5 by any applicant for a penou subjects IN applicmu..civil penalty of
pa Nen five hundred dollar(S500).
come 6.
I.aaw�rrNaprppmy,mmyempnyeeawiNw.aaamd.irwm=mwa.n.rm• Required Inspections
will du Ne work,sod the structure is rot intended muttered!fm sale(Sm.7W.Business
and Isexauom law
Code:no Contractor's License Most rant apply to an owner of
m
p ,cny who builds or improves dauxon,ad who does such work himself or thoiugh
his own employees,provider Nat such imPoivensenu art na inundd or.Rated for
aide.If,houevd.the Wilding or imp semen.is sold within one year ofcoropldlon,Ne -
nerbuilder will have Ne burden of proving Nat ha did n..Wild or improve for pm-
poseufaaa).
I,u owner of the Pont am exclusively contrasting with:)The
contractors=,&.Ion
cow U Oa project(Sec.o an owner
read Property
who oro Lich:)The ver thwton. rod
came law docs mt apply t.ts.ants of popery wW Wilde or improver thdeoa.and
who contacts fm such pojecu with a contrscsoAs)licensed pursuant in thu Contractors
Lohman Law. O
❑1 am exempt undo Sm. .B R P C for Nis teawn
Owner Dam
WORKER'S COMPENSATION DECLARATION
I Wteby affirm undtt penal,of perjury one of IN fallowing dmlantimia:
sunr]I have ad will for by
a tion 37 m of Consent rCone for the WeakeM1 Compen-
..itf a which Oil
for mi Section 3]00 of du Labor Calc,Tea the peRormanee of sW
work have
which Nis pemd.is issuer.
El I hath Li will ode.fon Workers Compensation Ion for which
h tequited by Sa]iore
3]00 of the laWr Code,for thea peH amc of Ne work for which Nis permit is isxud.
My Wodrnr,, C Qesdi9ta2nxuru^ ,arrim and Policy n5tiq
}��`Q C'•'' Policy No.. U9
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tbie senior need rat Le composed if the,semit is forms,hunNd dallen($100)
or lens.)
IcarifY Wti d perfomatwe oI Or isfeawhichthopemut is issmd.l shad
Out employ any y manntt s ta\keco, uJb'pel m IM Wortrre'Comped-
. .tion Nws ofC fo D
App is t
NOTICE TO APL ,afar making this Cedifcem of Exemption,you should
become subject w the k Compema.ion provisions of IN Labor Code,yon must
forthwith comply with such prusisions or this P=mdt shall be deemed ravokd.
CONSTRUCTION I.F.NDING AGENCY
O I hereby affirm thus thare is a com.mcuao leading agency for der Perform sof
Z Nc weak for which this Permit is iscud(Sec.7097,Civ.C.)
Fan lenders Name _
ai } Undoes Address
WI codify that I have road Nis application and sum Net Nme above inf. mion is
5 Z correct.I arra to comply with all city and county ordinances and sum laws relating to
building connmedon,and heroby autlwriu mpreaama ors of this city re rotor upon thea
U O ehovecmami.nd property for imp amm Purposes.
ONO.gone to sore,id=mniry are keep harmlasa Ne City oreuPenim against
O U lodultur,,judemenu.coin ad expenses which may in any way amore against said City
} L4 in omors uemc f gmnung of Nis permit '
[-• 0. APPLIC Tl 1 Rti GNDS AND WII.I.COMPLY WFTH ALI,NON-P(11NT
U z siOUNCI iEG LI0'
Wf/1 I-t-`�"�iJ • /190
V
Sigratum p lic Also
Dalt
ARM MATERIALS DISCLOSURE
Will the appli orfuture Wilding occupant store or handle hasaN.us armrial Re-roofs
u defined by the Cupertino Municipal Code,Chapter 9.12.and erre Health and Seedy Type of Roof
cera,0Ycasss3x.r. m•ll YP
Will the applicant or future Wilding mcupam use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hmad.us air conuminants asd=find by she Be, ea Ah Quality Management installed. If a roof is Installed without first obtaining an inspection
District' s ArI a ree to remove all new materials for inspection. Applicant
❑Yes
I luta ureal haaardmn assume,troninmmn ndhraapd695 ofNe oli- un erstands and will comply with all non point source regulations.
fmtu Hca & e Code.Seed 505.]5533 and 2553x.1 udmined flat if she
Wilting a d am m s any rtspomibiliry w rectify the occupant
of du teyuv 'h the con issuance of a Ceram rtli( juppbcy,_
w I \o'`�'L� Signature of Applicant Date
Owner.,atlyfi2to Dam
All roof coverings to be Class"B"or better
OFFICE
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