00030031 (2) CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ODD JDD�
BUILUINf.ADDRESS: .y \ 1 _ ^.`
/ JSS I((J,�/Af W ,r.�� (�(JC SANITARY NO. APPLICATION SUBMITTAL DATf
OWNE�'.S�'AME: / PX e f3`•'M1 INIC tO9
CONTROL#
HONc', 26Y— 77 �'y1Yh'1�1Gc93c13 3 °
ARCHITECI'rENGINEER BULDING PERMIT INFO
LICENSED CONTRACTOR'S DECLARATION
i pO m— I hereby afftren than 1 ant licensed under pmevisiom Of Chepar 9(commenting Job Description
C—❑
wishS«tion7000jofDiviaion3ofNe Busineasand Rofeuiona Code, my licemeis
y`< in full forte and enact. •'�
r.O U Licenac Cl/dsa,,'/r+`�"� Lit.N ///��� 8r 1 (#g
Dem on 4 y S DECLARATION 1 /_r�I
O g 1 / gBC['J y`y'eTG.TL� \'•VI I UL w K .
IundesarW Y public sec«ds
to i a Licensed Professional r —_ - -_
=y OWNER-BUILDER DECLARATION
t r 1 hereby affirm shat 1 sum exempt from the Conus ctor's License Law fm the
s O following reamer.(Section 7031.5.Business and Prof iom Code:Any city Or county
S$ which requires a Permit m catutruca eller,improve,demolish,or,,.my asnctue Sq. FI. Floor Area valuation—
chat
-�
prim to iB iasuence,also m uires the applicant forsuch permit.fie.signedsummrnt
Nat he is licensed pursuanu0 Ne provisions of she COntrac ce.License Law(Chep,'9
(ermmendrewithsecmn7lwojnrDiviainn3nrtheenainea..al+eresamnacnde)rr APN
NT
therefrom at he is exempt efrom and Nede basis for the allegammiumn.Any vs of 3Z
Number Occasane P Y YPe
Section 7031.5 by any applicant fm a pemut.bjects the applicant m.civil penally Of IO
net more Nen Eve hundred Sultans(SSW).
❑l....nrNeprepeny,ormyemployeeawiNwagas.aNeirmeIscemanaani Required Inspections
will dothe wmk,W the awnum is tern in¢sded«°Rand for We(Sec.7W.Badness
and Pmfeed.Code:The Contractors License law does nm apply.an owner of
peoperty who builds ce imposes them,m,and who dens such work himself m through
his Own employees,provided that such improvements are Out intended or offered for
sde.If.however,Ne building m improvement is sold within one year of ou pletion,the
Wilder will have the burden of paving Net W did nes build m improve fm per-
presented..). /
I,wa a own.of the Property.an exclusively Contracun8 with licensed contnetms. j
comthe p.j.t(BGC'fW.Business.d Professions Code)The Cortnnora Li-
c nm law does not apply..owner of property who Wilds or improves Hereon.and O
who contracts fm such prolan with a conuactos(s)licensed ponuant to she COnheclofs O
Limn.U..
l am exemptunder see. .B&P C for Nis reason
Owner Dem
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under peralty of perjuy one of the following d.laraliotu:
1 have and will maintain a Cenificam ofcoment to self.iasure for Wmlear,Compan-
ration,.povidtd for by Section 3700 Of the Latter Code.for the peAomunce of'be
se hich this permit is issued.
(yf have and will maintain Wnhsrs Compensation Insurance,as required by Section
37Wof she labor Code,fm the performance of she work for which this permit is issued.
My Workers cf'''�ti T canner and Policy earn
Cama: 4- g#1 u,lPolicy No.:
CERTIFICATE CATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE --,
(This scetirrneed nut beccondased if0tepemun is fororehurdreddollan($100) '
or less.)
Toy my thanirtin prfmmanea of thawmkfor which je thio permit iscts.Co.,.-masH
1W O g] 20 0 '•1
trot employ soy Paraun in any manner w n to became wblect.Iha Worker'Cops- I�I R^Itr� J 1
section taws of California.Dem - „1I.3t�
Applisam
NOTICE TO APPLICAM`.If,after making this Certificate Of Enempuon,you ahnuld
hecorrc.hjecl.Ne Wmaces Compensation provisions of the LaWr Code,you must
forthwith comply with such provisions or this permit Nall W decreed revoked.
CONSTRUCTION LENDING AGENCY
Q Q thereby alEnothatthert iseconswcuon lcndine agency far Ne performance of
the work for which this pem,it is issued(Sec.3097.Civ,C.)
Leaders Name
} Lenders Address
[y) I«reify than 1 have read this application and state that the above information,s
0. correct.I agrtc to comply with all city and county Ordinances and suite laws relating to
;D Z building construction,and hereby authorize representatives Of this city.enter upon the
V O above-mentioned pmperty,for inspection puspao.
Iy F (We)egrtc in ast indemnity aad keep harmless the City Of Cupeniro against
C.1 liabilitia.judgmcnts,GOsu and xpemea which may in any way accrue against said Cily
} W incur c fshfun,an Bus perom
[•+ L AI'PLI ANI'l'1NANDWILI.COMPIYWITIIALLNS
ToeSigram of Apel cant/Contnct Dam �J�'7,7A_LJC Ir /�a I
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant(uture building rccupas,store or handle hazardous material Re-roofs
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Type of Roof
Code,Section 25532(.)7
E]yes No
Will do applicant or future Wilding occupant use equipment mScvicess which All roofs shall be inspected prior to any roofing material being
emit tassel a au contaminants as def by the Bay Area Ab Qaliry,Management installed. If a roof is Installed without first obtaining an inspection
,is,
7 I a tee to remove all new
for inspection. Applicant
OV
No
I have mad Jte hamodpoa seriesm,oimmenta under Chapter 6195 of the Cali- un erstands and will comply with all non point source regulations.
omnia H ale Code 25505.M533 and 25534.I and'stand that if the,
built dm one i.Nat it is my respwibiliry. ify the mcup.t
Ofthetry 'term 1,h Sebe Poor.assance ofd 4 ' Ol up"ey
9 Signature of Applicant Date
owner onuthon agent / nam
All roof coverings to be Class"B"or better
OFFICE