00040110 (2) CITY OF CUPERTINOMNo.
BUILDING DIVISION PERMIT CONTRACTOR¢,INFORMATION: OO t/ �CPE I �'�
BUILDING ADDRESS: ^'�U/eM, /{` V Pw o
®97
® AA latj a `/— •711J/+,(^�I 7^(/g C) ' SANITARYNO. APP ICA'IONSUB�DATE
OWNER'S NAMD 1 I�Il
NIC CONTROL»
HGNC: 25`1- 3 q Q ' l °
CHITECT'/ItNGINEER /] �O� BUL'DING PERMIT INFO
O'O t /_ l
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Z.
i LICENSED CONTRACTOR'S DECLARATION
z o y— I hereby aRrm Nat 1 w licensd under ovisions of Chapter 9(commencing Job Description
O'�E wiNSation T000)of Division3ofthe BusimsseodR feniam Cade ado beano i,
<,7 in full force end eff 2 /� 3
W w¢ Cicero , r� Lic.» sell z L/ re
LL 3 e Date Conuacmr
t—.OgRCHn
As"Iheuse DECII 1N�
'^ 1 understand mor prices NJI W used m pubis rcm,dr
Iicm,d RofeuinnN
6 h�
1
hereby alftmt Nat 1 am exempt from Nc Contractors License law for the XG63 K) `YfN/T�rI .-{ 3 �.f/.J`i�J(
D follower'rcmon.(Salim 003 LS.Bmimss and Profmioa Curie:AnY city m county
rtgro a pndt to cmuwB slur,improrc,demolish,or rt ny any,wcnue Sq. Ft Floor-Area Valuation
Who to its issuance.Aso requires the applicant forsuch permit to file a signed statement
oco slO
met M is licensed potemnt to te hprovisions office Liana Law Liantaw(Chapter 9
(commencing with Section 71)(Mi'Division3ofttu Business and Profession,Code)or \ P Number3,2_ Oc an• e
that he is eacmpt therefrom and the bmis for the alleged eaamptien.Any violation of P , YP
Section 7031.5 by any applicant for a permit mdjcct,Ne applicant to a civil penalty of ,
Ot more Nan rive hundred can]am(SIMI),
l.um.,a,ofthepmpeny,ermyemplW=swiNwage,mtheirsolecomp'matim. Required Inspections
will do the worknoddsesoucmrt i,rot imcdderoRend fm We(Sec.7W.Bualtmss
and pmfessiwu Cede:The Contractor i License taw does,wt apply to an ewmr of
property who builds or unproven thereon,and who does uch work himself or though
hiswn employees,provided Net
vidsuch improvements art no imerde i or offered for
selcolf,however Nc building or improvemrnt is sold within one ye,r of cotnplaion,du /
owner-builder will have the burden ofproving that be,did not Wild or improve fm pur- (�
pose W,ald.). J
1,as.,of the property,un'.elusively coaoating wish licensed contnnon in
mnswct the project(Sec.71W,Hurt.sed Profcssioa Cade:)The Cmuanola V- /
cense law doe,mt apply la m awmr of property wW Wilda is,Improves deaems and
who contracts for such projects with a conuacm,(s)licensed former Conobi /1
ace taw �•/ ^ ,
❑1 2xe Sec
Ow Data
R 'SCOMPENSATI DECLARATION
1 hereby affirm under penalty of perjury me of the following dalansioro:
(/ Ih. .mwillm .Wn•c'niricauol Co.elf-Ice.for worker',Compete
tion,as provided Ter by Section 3700 of the Labor Cade.for the performance of the
k for which this permit n i.med.
w 1 have and will maintain Wmka's Compensation Imminence.m requited by Section
g0tftof he Litsm�C.ursse.Ins,da,ydusppleart�on�m of the work for which this pmn�ironed. i
C.,riey It 1 i.�n 1'"IA l ncy`m:
CERTIFICATE OF EXEMPTION FROM PEWORKERS'OOI 11
COMPENSATION INSURANCE
(This swim nndnm be completed if the pemtit is formehurdred dollars(SIM)
or les.)
Imnify Wti th'pe,fmmmm.f0 pwmkfrwhich thispernmi,imued.Lshall
ndemploya omeni y nen t.1sct , jKtgQlrcJl -
AawCompen
selim shwa of l�li Vv�s++
Applic t I(
NOTICE TO APPWe shsd F. aftermakingn pr Cemhceof this
Ea peon,youu wld
most
Wcome comply
o she Wo,kds Compco this provisions of Oe labor Cede,you most
foMwiN comply wish such provisions or this permit shell W domed revoked.
CONSUUCfION LENDING AGENCY
OI hcrtby harm this there is a sm m.nom lending agency for Ne Id---of
Z the work for which this permit or issued(Sec.3097.Civ.C.)
[:w Iandue.Name
Ledert Address
tg] ^Q I cenify that 1 have red this application and some that he above information i,
men.1 agree to comply with all city and county ordinances and sum laws aiming in
z building construction,and hereby authorise representatives ofthis city to enter upon Ne
U 0 ahuva-mentionedproperty for inspection pumpores.
(We).gree to titre,indemnify,and keep barnleu live City of Cupertino aga ant
U Iistaidca.jd8nenu,amused a.,.,which rosy in any way amoreagaimt,aid City
yt Ln n segmnc'of Ne granting of Nt Kimir.
[� 11 to IC "U 'DF. .,I,'A t WII.I.COMPI.YWII IIAI.I.NON. INT
4n ,S' of Applican C/Conuxler Due T /�`��� l.�C !a �eld /
HAli3RDGUS MATERIALS DIS OSURE
V311 me applicant or future Wilding comport store or handle hommous comm l Re-roofs
an dcfincd by the Cupertino Munictphlfdc.Chapter 9.12•rend the Health and Safety Type of Roof
Code.Section 25533(.)7 / YP
Yes Il
Will theapplicant or future Wilding o,cupmt erre equipment or device,which All roofs shall be inspected prior to any roofing material being
emit hawdom au contaminator u defined by rite Bey Arcs Ah QualityManagement installed. If a roof is Installed without first obtaining an inspection
mtriet7 a� I a ree to remove all new materials for inspection. Applicant
❑yo
1 have mrd the,h..&u,meed,,quisemenlnundcr Chapter 6.95 of the,Cali- erStands an will comply with all non point source regulations.
foot ealth&Safety Cade,Section. 5505,23533 ed 25536.I to n et et if the a �V OO
W' rims cu 'Y haveode,S n t 505,is my m,pomibilirymnn' upas o
me u stben
'gnature of Applicant Date
rose- hemi,m U P..
- All roof coverings to be Class"B"or better
OFFICE