00020169 (2) CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: "z)o o2 o / &q
OUILDINGADDRCSS: LL.rsGrjS 9 SUBMITTAL/ SANITARY NO. APPLICATION SUBMTAL DATE des /rw�� sT z-2.;Z-fit os
AM OWNER'S NAME �,n O
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RCH CT/ENGINEER IIULDING PURNIrr INFO
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~O y LICENSED CONTRACTOR'S DECLARATION
1 hereby dorm than I am licensed Leda proviainm of Chapter 9(commanti.g Job Description
�vt-w wish Section T000)of Dlvision3of theme�B.usinuc�as and PmteaaionepCoek,and mYlicenae is
5 0 u in full form and ePgct.... 7-V- rv' �Oo 0 9� (j '�LCjP/ ver `[/a./C� !/L/✓
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upama cl.a N C .«
Dau Con...w O C ARCHRECI'S DEC ,
v��;S 1 understand my plw shill W caval u public neeonds
d ° ummad Professional
�y OWNER-BURDER DECLARATION ,
F z_a 1 hcaby aPorm that i un exam,,from the Comnlemes License Law for the
'd ro❑ following v+mn(Sation 7031.5,Business W Profeariosn Cade:Any city or county
su � which oubmas a pared,so pmahua,War,Improve.demoliah,or.*rany slrvc,tlre S Ft. Floor Area Valuation
3_
Peter to its ismance.she raquimthis applicant forOuch permit in rile asignedstatement
y'
that he is licensed punuart m the provision,of the Contractors License taw(Chapter 9
(commencing with Sacdon]OW)Of Division 3 of the Busi.aaand Profersiou Code)an phi er Occupancy
Net he is escmp,therefrom and the basis for me alleged exemption.Any violation of P Y type
Sation 70313 by any applicant for a parous subjects the applicant m a civil Faulty of
not nmm than five hundred dollars(S500).
I,asownaofm hip ny.mmyemploymswimwaguumeiraolemmpensation. ® )6t quired Inspections
wall do the work,andthe awaure a nm imendodoroRcmd fm W<(Sa.]014,Butincu a
and Professions Code:The Conerxeteo l Warne Iaw doer not apply to an owner of
property who Wilds or improver thermn,oral who does such work himself or through
his own employees,provided mat such impmvcmants arc not intended or offered for
ulceIf,uilde, sated Wildingurimprovement issold within oneildor mrrtpie for rhe
ownanbulwr will have the burden of improvement
the,M1c did not build m impmve for purr
pose of sale.).
h u owner of s, San 7 ,Businessan,sins andely petticoat..g wins:)penial...unser. 1.
smug
mitause,the project(Ser, . we. fand petrty who but Cade i Tile Contucma.and
c e law docs nm apply e ts ownar of property who builds or improves menton,and /
who ncontracts"wfm6nch pmfepla with aCOO4KIar(a)Ilee,la[d pYRW,I,m111e COntIKlOr6
Wcense Law.
❑lam examµunder Sec. .B&PC for Nis ntaaon
Owner Date J
WORICM.5 COMPENSATION DECLARATION
I hereby affirm under,malty of perjury one of me following declamdou:
Ihave end will maintaineCeruhcant of theU Code,
the
timuComprn-
woion,r provided for by is
3700 of the Labor CCde,for the pesfomunm of she
k for which rola Finnish is issued.
W have cad will maintain hoo u ff CompensationidshInsurance,h requited by Section
371MIof IW labor Code,fa the perfom+ence of the won,for which this Permitpu iuued.
My Woder'a Compensmloy In.mrmce tamer and Policy npk/ 77
Carrier: 0% i�LO Policy No.: lI✓✓
1C RTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nes W completed tithe permit is fmone hundred alalias(SIW)
or lav)
I mnify,bal in the padomarnce,of Ibe.,it for whim this parmit is issued.,shall
net employ any person in any manner an ay�1Y��)—,m me Washer:ComFm-
relionlawsofC - {-
AFWicus
NOTICE PWCANT: ,dor making this Cenificare of Exemption,you should
become subject to the Workers Compensation provisions of the Labor Code.you must
foMwith comply with such provisions or thisµani,slWl W deemed rooked.
CONSTRUCTION LENDING AGENCY
p I heabydfrmthin mem is somis uction Imahigagency for'he pnifomanon of
Z the..it for whim Or'
,emit is issued(Sec.3097,Civ.C.)
ti Lenders Name
> Under's Address
(zII certify thin I he.read thin application and stere caul me above mai motion is
O. z corse,.I agree,to comply with all City and county ordinances and aunt laws relating an
Z building construction,and hereby surmise reprtrenu,ivu of this City to mar upon the
U O above-mentioned property for inspection purposes.
4. Fw (We)agree to cave,indemnify and keep hu seleu the City of Cannon. O.t
O (.7 fithAmes,judgments,sc.,and apcnses which may in any way accrue against said City
�,. W in conanquema of the g..,of Ibisµ.nit.
F+ II. APPLICANT UN DERSTANDS N I)WILL COMPLY WITH ALL NON POINT
tiUU 'RRE A'fIDNS.
i, reof Apphc ,m Date
HAZARDOUS MATERIALS DISCLOSURP.
Will the.,licam.,future Wilding..Wis..or handle insisted...material Re-roofs
as defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety Type Of Roof
Code,Smfim 255324] YP
,Yes 'PN.
Will Ole epplicam or future Wilding aaupam use equipment err devices which All roofs shall be inspected prior to any roofing material being
I has
adouuu comamluns u defined by me Boy Ams Asa Quality Management installed. If a roof is Installed without first obtaining an inspection
.i°" I a ree to remove all new materials for inspection. Applicant
❑Yes (d No
I read! running.have rethe running.seNWamena under Chapter 6,95 of the Cali- u erstands an it omply with all non point source regulations.
1 tomer Health&Safety Code,Sation^x5505,35533 and 25530.I mderstud that if do �� OO,
Wilding dons vas currently have a tenant.teat it is my rupooddlity m nolify,she emuput
of the ou uircmenta whim must be met prim to iuunce of a Cmificue of Occupancy.
b azure f Applicant Date
:Owner or authorizedseen, Data
All roof coverings to be Class"B"or better
OFFICE C