00040131 (2) CITY OF CUPERTINO PE ITNo.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRFSS:
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SANII'ARYNO. �AiP
PLICATIONSUB IMALDAjy L /ghs(/ mowe vz 043
OWNER'S NAME
�7NIC CONTROLM
fq393 °
•CHITLCnENGINEER BOLDING i'ERh11T INFO
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LICENSED
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mad
r " LICENSED CONTRACTOR'S DECLARATION
7�=� thereby affirmtat 1amlicensedunderprovisionsofCa . 9(commencing Job Description
-mHw withs«tion T000)ofDivixion3of one Busia[s andProieuionsflme.and my littnseis
Y`<J in(UTI(Olce a11d eEeet.
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Date Comra<mr et�`(J^,✓) /✓1WY!"'tTG sf{V//'/_/s'
-M O g RCHIT1sCrS DECLARATI 1
v��• l u my plw shall be urm m pubik+cads
m c O Licensed Professional
w OWNER-BUILDER DECLARATION
C >' 1 hereby affirm mat I am eaempt from the C.nl..r'a License Law for the
following reamn.(Section 7031.5.Business and Pm@miona Code:Any city per runty
`u.-' which¢quires a permit m<omwn,dl«.improve.demolim.or repair any[wctme S FL Floor Area Valuation
3 prim to its issuance.also requires the applicant fm such permit In file.signed surcmenl q' ,
unit he is licensed punuans to the provi[fom clone Commulors License Law(Chapter9 goo
(mthm�mmgwims«timonand)molaliiof rtoalle ado Ary
i cone)« p Number Occupancy Type
Ws he is exempt Nerfrom and one orris for me allegro cxemptia.My vioWia M P" Y YP
s«tion lolls by any applirmt fm a gamut subj«t,Ili applicant to a civil awry of 323 — 0311S_
p1 mon,men five hundred do11.(3500).
I.axnwnet"rthepnnperry.mmremployaawithwageamJteirmi<mmpem+tiun, - Required Inspections
will dothework,soda Contract.,
is not,Licenser as,dofm.apply..a4, win,of
end e",pogwho b Code:Tlr Cve,there o License w law does na apply s lf owner gh
progeny who build.pr improvea tM1such i and who tinea such wotk deed re or tied for
his own employere provided r m such improvement,arc not intended o odetnd for
owner,uild ewithehuildingaimprovcvin is sold withinoneild r(compluia,the
,o n of sualder will have the burden of proving mat M1e did mol Wild m impmr fm pm- ��
pore r sale.). -
co I,u"ware(ct progeny,.B vulusi and eonoedng with clamed conlnnoss m /
o.La me project(Sec..red,Boniness and Ro.1ho m Cndr ite or Conuecmrs nd O/
come law does nut apply m h,owar of propery wee builds m immovhe therrood.and
whoconLaw.for xucM1 prokcu wine a conoanortq licenced punuam to she Contractors O
Licenselaw. o
1 ser<xcmPt under Sec. .B&P C for oris reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I herby affirm"oder penalty of perjury ate of one following declmatian:
f]I have and will recum it CernficateofC sem to elf-inaurlot WorkersCompcn-
•tion,ax provided for by Section 37M of the labor Cade,fm Jse perronsunc<of the
xk for which this permit is issued
-
7 1 have and will maintain Workers Compensation Insurance,or seq.hed by Section
31J0"f one IaW,Code,but to perfmmmee of rhe work for which oris permit is ovum.'
My Wurker' pensetinn Insurance cerri«end Polley num e.
Gema Policy pulley
'
one R .OF EXEMPTION FROM O I . S'
COMPENSATION INSURANCE
(This section teed ma be wmPtrual aft permit is for oa hundred doll»(3100)
m less.)
I terrify and in me performance or the work for which oris permit is issued,l shall
not employ any Fannin in any manner an m to b«ma subject to Jte Woken'Courtlier-
union laws of California.Date
Applicant ,
NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should
be..mbieol m the Workers commission,provisions of the Labor Cade.you must
forthwith comply wit such provisions m oris permit[hall be decreed revoke.
CONSTRUCTION LENDING AGENCY
O I hemby affirm Jtat then is a co admiction to Bing agency for one perfmmmme a
Z N the..it for which this permit is issued(Sec.1097,Civ,C.)
Lenders Name
7 lenders Address
[� 1 certify met 1 have mod bo
oris application and elm,Jul the ave bd.mm is
0. Q cmrtcv I egre<to comply with all city and county ordimnces and sur bws dating m
•Z building coah.ctio.,and herebyaomeriee reptesernifiNmof this city to enter upon me
.bove.meneomed property for inspection Pmposea.
(y F (We)agree an save.indemnify and kap hmmleas she City of Cupertino against
O U Iishililimjudgment,cunt,and expenacs which may in my way accrue against said City
} Lr] n casegaae of the granting of this permit.
F S tAPPLICANT UNDERSTANIIS AND WILL COMPLY WITB ALL NON-POINT
V � SOURG A'fION
` 1 . 4- _
Signnum.fA,fiesnt/C,r.,m
HAZARDOUS MATERIALS DISCLOSU
Will the applicant or future building occupant la<or handle hanbedous material Re-roofs
a[deEnm by the Cupertino Municipal Code,Chapin 9.12,and the HWM and safety Type of Roof
Code,Sancti 25512(x)1 YP
El Yes I(ya,O
Will one applicant or rump,Wilding octopus,use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hmoodous air concrmhunu u refiner by the Bay Ara Air Quite,Management installed. If a roof is installed without t_irst obtaining an inspection
�ix°icn �N/ I a nee to remove all new materials for inspection. Applicant
Y<s
I have rem me haea•dc"r mum movements under Chapter 6.95 of Ilia Cali. understands and will comply with all non point source regulations.
amu Health A S C lions 2 ,25s51 and 2551".I understood mat if the
bi ikhrigdoesn err 1, a nem, 'n ismY rra,wibility to na'y the .pant
of dm reWimwb h musuerce ofa Cerin
Signature of Applicant Date
Owner m a.thonted a l ata
All roof coverings to be Class"B"or better
OFFICE