00030009 (2) CITY OF CUPERTINO' t
BUILDING DIVISION-_ PERMIT CON+I RA�IG(i)R IN''FORMA�TIOg N,:9!
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AUILDING ADDRQSS: //L (�j (/��
t/lU-'1✓� Ala^g(./ //PQMkbI /tL�• SANII'ARYNO. APPLICATION UBMIIALDATE
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F• i LICENSED CONTRACTOR'S DECLARATION
O 2=p I hcrtby aRim ILD l am licensed under povisionv mf Chaper 9(commcairy . Job Description •-
F¢,y[_m wiN Section tgp)ofDi iaion3of de BuainuaaM Rofessimm Code aM my isfull
pap ne a Licemeorce olid.Rest. Ur.*
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G3 3. Dae--'. Contrwwr '•' i ' I . /4(i p�Gl�JC+ 1 /a� {../�//4/( 4l/U'✓/
O¢ - ARCHITECTS DECLARATION -
Ey�Y, N J" I undenuM my plan shell beesrA u public rccada -• „
++d p LILansCd PmfenlONl ' • r. •'.. .
OWNER BUILDER DECLARATION
C Z< 1 hereby eRtm that 1 em exempt from de.Compactors License Law for the - -
following mown.(Salton 1031 S,Business and Prothauou Cade:Any city or county
w C o which ropmess a pemdt to construct,alter.improve,demolish,or repay arty sttucwe . .. .
c.a= Sq.Ft. Floor Area Valuation.
pnato idsiuuence,dw rtquirtsthe epplicml la suchleemil mrd'.,igadsuemcnt .+ _ ,e� OD
death.is licensed ocauam mueprovisionwf Ne Cmoacmtr.Licenwlaw(Cluper9 ` '
thammEsLexemitbswllpnn seal co basisooronhe,ged exaavd Professions violation
- ppN Numb r Occupancy Type
_ and he is.ramp Illa.rmm w the n..ia(m the e1kgW exemprivn.Any vioktion M p y, yp
Section 7031.3 by any applicant fon a permit subjects the application to a civil pendry of
and amore Nen five hundred dollars(S500).
ladu,worof Ne popent',re6nor lojm wiN wage au Neu(Sec.
7W.enndan. . Required Inspections
will doefewons Codeemm�unialon's License l.aw done Waply to an BusinessRequired
proand artyPrewho
Code:Tyra Cves uhaoh Liam.law data red apply m an owxr gh
hiswe who W itis or improves Nerth improvements wM dote such wast deed ort a tlwugh
his own employers,provided ten such odw are'mt intended r oBared for / -
We.If.howe will
!holding.,brguebrofMvinduat he did noneildori improve for
Wilder will have the dodo of paving Ihel he did not build or improve for put /
pone crime). .. O
a ❑I.u owwr 0f Ne property.on
""oil
cono-ectias with,an conowm am
common.the project(Saw.7W,Boston and Professions C.&I The ComrecroYa Li.
m A, v
ttnse law does napply I.an awns.of popertdh
y who Wilda or improves eemn,and '
,f wW contracts for such pwlia
mjeclswith a om ho(O naM punuam to the Cbmnm
cts
License law.
❑I oro exempt tmea r sw. ;B&P C for this swan '
1 Owner Date •' •.,
FWORKERS COMPENSATION DECLARATION _ r
1 hertby affirm under penury of perjury owe of the following declarniom: f,
❑I have and will mainWn eCenifcate of ComanuoselGinwnforWmrkee.Compn-
pian, s provided for by Section 3)00 of the Labor Coda fa Ne prfomuna of the � 1 • , ,
or which this pr or is issued. .
have and will murder,Woraces Compensation Imurabcc.u required by Section
37Wof the Labm Code,for the perfomnnce ofthe work ffo�rr which thispermid is issurd. '
MY Work am xn�n'Ijn lnaurana curies and PalicYX +4092/Q 1.t'
Curler. rah Policy No: x '
CERTIFICATE OF EXEMPTION FROM WORKERS'
• COMPENSATION INSURANCE s
(This wenon conduct beemn li,trat deepm111 is fOreahmWrtddollN(SI00)
or Ins.)
I1,mfy diad in the prfonnnea.fthe work for which Ni. unit is ism 1,l abet
min employ any permit in any manner an as in become subject o the Warkera'Compn- _
cation Laws of California.Dau -
Applicant
NOTICE TO APPLICANT;IL after making this Cenifae of Exemption.You shouts - - -
berome subject to the Workafs Compensation provisions of the Labor Code,you must r -
forthwith comply with such pmvhions err this parol,shell be domed invoked.
CONSTRUCTION LENDING AGENCY,
O 0
Itherebytiff,ro Nn dem te a cunnnction l ding agency forth p do tense of
rt' We wok for which This permit Is Inued(Scc 3091,Civ.O) _
[� a> Isodde Name 'I U -
'a •[� 7 I<nder s Address „
W• I certify that I have nm Misty and coup and sine that the salve mos relating is -
p+ Q bonen.I.gra to comply with all city end county ordinances and sure lawn reale t w
-w'7Z
buildingconstruction,pro and for
amhonzepose.. uvea of Ibis city menet upon tee. +
U O' above(We) ed property for inspection keep ha. ^
GT• �y' (We)agree w over indemnify and kap hay in ss the City of Cupertino addict u '
O V incohiequo.c.of
.trend eapnwsrot. may in say wry attrue egdnxl said City r
in conaqucncc of Ne gr ting of J+is parrot.
`F h APPLICANT UNIyHR tNDSANO LCOMPLY WITH AUNON-POINT
U.Z SOURCE REGUL I s. - _�I .•
Slgwumuf Applicanmr �� '�YY••�/ f
H RIX3US MATERIALS DISCLOSURE
Will the appuant orfuum Wilding occupw noieor handleh¢udaiu malarial Re-roofs
as defect by the Cuputim Municipal Code,Chapter 9,12,end the Health and Safety ,
Cade,Section 25337(07 Type of Roof "
❑Yes
Will the sp,ticemorfuture Wilding occupant no.equipment or dcvias which All roofs shall be,inspected-prior,to any roofing material being
• emilhavNous air concemi�WtsndefnedbylbeBay ArenAir QuallryManagement installed. If a roof is installed without first obtaining an inspection ,
DimricO •+
❑Y.a - 'I agree to rerttove-all new materials for inspection.,.Applicant
Tuve nal Neh.andwa matenda regaLremenls ander Gheperf 936(the cdi. un ..S�sncomply with all non point source re ulations.
fmNaHealth&Safety Cock,Sections 13503,2533 and 75330.1 undentuid that if the
Wildingddunacunemlylow.aenant,NatitismynsponsibitryI If thence I ;-r �• 2 .
of the requircmems which mu the nor do issuance ofe Certificate of aupan '
or Signature VXPplicant Date
owner or euNonz - a V, -.
' 'All roof coverings to be Class"B"or better
OFFICE ,' -
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