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00020091 (2) CITY OF CUPERTINOPERMITNOq. N BUILDING DIVISION PERMIT CONTRACTOR3FORMATION: OZ O I BUILDING ADDRESS: 1 O L I �� ��� SANII'AkY NO. A•�y'�LI^ATIONSUBMITTAL DATE 7 '�,�a"��ff //y 4 (� OWNEWS NAME: _ n ( lad/ \ `�rP� / I �ZDOIaa er✓ NIC CONTROLS D ARCHITECT GhYEE IULDING PERMrf INFO ' .L-,e; UQ U t) yea Lal LICENSED CONURACTORS DECLARATION of CON O Z E e hereby affirm mat T am fcan Bu under and Poonms of shaper 9(commencing Job Description �tw cons Sation]0oa)ofDivision3ofJe Business and Pmfclaiom Cade.aotl mYlicense u '/� y ,'�j in NII force sod cRat. f(�� f/,a,f e ve V e0 U Dae. Class Lia.. VV--tt uy� Date Conuacmr tO g c ARCHITECTS DECLARATION 5 I understand my plans shall be uud as public records y 6 e O Iicesecd uiov Profel oS= OWNER-BUDDER DECLARATION I-Z< 1 hereby aRrm that 1 sm exempt from the ContncmYs Utensils Law for the ` D following...(Section W31 S.Bu,iusa ad Pmfessiu,Code:Any city Or county s m which repine,a permit to conswa,wet.improve,demolish,or repair any structure Sq. Ft F or Are• Valuation o prior to its i,vusna,also regales me applicant for such 1117110w file a signal an ement n_ that he is licewal prrsumt t0 me provisions or me Con ramma Liam a law(Cbaper 9 (7 VI 2�� 0 0 I (mrmossingwih Sectign]Doo)cxfoiaision3af me Baalun coal Poressiaw code)" APN Number - Occu a c wt he is eaemp therefrom add me baais fin,the alleged eso paust Any„aaJae or (' P Y Type Section 7031.5 by coy applicant fora permit subject,he appnt licato a civil pane of 3q2 2 pa more man five hundred dollen WWI. 1,as owner of the prapeny.nrmyemployees with wages a,their sale compenaation. - Required Inspections rum domassime enema tvunmiusmot itucrdeder sw doesorota(pi'm an Bwiuss aha 1',Who Cade:M Comtanor's[.kenos law dos not apply to if owner of his o ny cow buil",or impovu thsuch std who sus sucss n rinte hioro Jed for his own employ. a WiL dal that such imntiz"nu are nun intendedyofca offer.for mareaL howeves,JU Wilding burden of movant it cold wild nano yw ofmproverion,C, j -wooer win here me wrden or proving that bo am not woe m improve rot ver- W glee. �� r of me property,am exclusively cormumng with licemed convenors to strvct me project(Sm.IDN,Rusiuss sod professions Codc:)Th<Contractor's Li- cewe law dew such apply to an with a of popcny cow wilds m impo the Como,ors O cow contracts f«such projau with a canvactort0liccnad pusum w the Convector, 5L law. - ❑lamaxcmpt Sa; .B&P C for Cis won Owner Date vlq ho WORKER'S COMPPSATIOIN DECI.AMTION 1-7 1 heRM1Y eRrm undo pmaltY perryry au of the following"«[onrush: ]1five and will maintainetion 370 of fomentm [aim,for far Woom of mirk,as provided for by Section 3]00 of Jte Laver Cale,for the pcAomunu of the work fru aid Cis permit is issued. ❑1have adwill mutation e,per C.offltiurk far ce,as whih1n.per by Section My Warne laver Code.for the pcHamance of Js wort far which thio permit is i,wd. Ca e,: Cempcwtion Insurance cerrim nal Polity number are: Carrier: Policy CERTIFlC OF ION MOM WORKERS' COO MPENSATIONSATIONINSURANCE (Thi,action nail not he cnmpletd irme pertnit is forou hgodrd ddlers(S1o0) cr less.) T certify Cat in the performaue of the w«t Nr which this permit is iswd.I small not employ any person in any manor eco u to become subject to the Workers'Comyen- setion laws of California.Dae Appicwt NOTICE TO APPLICANT.If,after making his Certificate of Exemption,you should become robiat m me Wankel,Compensation pmvioiona of me Labor Code.you Cwt farCw"h comply with such provialgns or this permit shall he clamed Rvokd. CONSTRUCTION LENDING AGENCY O Q I hereby affirm Iliad them i,a cowN won[coding agency for the performance of y the work for which this pcnmit is issued(Sec.70)7,Civ.CJ a Lendelm ,Nae Lo=x Addeo, fs: T comfy Chet 1 have read!mi,application and suit that the above infomuaon Is A. 0sect.I agree m comply with all city and iausd county ordnalore laws relating to Z buimingconxorcaon.and hereby auJwriew reproenhtiver oflNsciry to morapon the U O aWve.menamd property tar inspection purposes. W P (We)agrm to save,indemnify and kap harmless the City of Cupertino against O C.) liabilities,judgments,court and expenses which may in any way accme against laid City >. W in commanumem Of the Starring of Cis permit. E" 6r AYPLICAN UNDERSTANDS AND WILLCOMPLYJJJ///LTH ALL NON POINr J,JU Sty URCI' �IONS. r Z�/�/� . .. /' /nka . a� �/f a--/fes// Signat�APPlicanu Z'Q' T able v • �' I 1 HAZARDOUS TERIATS DISCI 0SUR e Will thearplicadn orfutuR dingucupmismR or ladle haradoux material Re-roofs w defied by the Cupertino Municipal Code.Chapter 9.12,ad he Hesi ad Safety Type of Roof Code,Section M532(s)] YP Ye, ❑No Will the epploanr Or future Wilding ucupenr use equipment or devices which All roofs shall be inspected prior to any roofing material being emithaten°"wrdOu,air conuminanu as defined by the Bay Arca Ab Quality Management installed. If a roof is installed without first obtaining an inspection❑Yw No I a ree to remove all new materials for inspection. Applicant Im ❑ I have Rad arc hares low materials equiremane under Clupter 695 ofthe Cali un erstands and will comply with all non point source regulations. forma Health&Safety Cod0.Sections 25505,25333 and 25530,1 understand lid if the building alas nun curremly have a tenant.Ca'n is my responsibility t0 notify he ucupant of the R9wRmene which mu.t be rat pie ro isauauc of a Certificate Or Occupancy. . Signature of Applicant Date Ower or indeed zed agent Dae All roof coverings to be Class"B"or better OFFICE