00030041 (2) CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:eA
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BUILDING ADDRESS: ,.,A - O
O e— �3!`.S¢-A sojivi & -y o `{ /IV.T SAN ITARY NO. APPLICA IONSUBMIFEALDATE
OWNER'S NAME: �., ,S'/l/Jq fit OA/�L Avg
N!C CONTROLg
PNONI:: 30 E (Iq�/gg�gYACCA.
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ARCIIITCCI'9iNGINEER HOLDING PERMIT INFO - 0
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s. Z LICENSED CONTRACTOR'S DECLARATION Job Description
0 O L_ 1 hereby aRrm Nu 1 w licensed undo provisions of Chapter 9(corOeeing p
o_tw with Section]000)ofDivision3ofta BuYnw and Rofwioas Cade,and mylieease is
E txtsiIll raae.nd ffec Igo-
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�'o.O Oete u- ContrutmS�'g-�
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f g I understand my plain shill be seal xsEpuuM'ccrecads l- 3 6f o loo is f
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d�o� rmsedPmf4ipa { - 2Y 000 vNtr
OWNEon foar,DER DECLARATION
1 herby affirm that 1 am exempt
€ ero the CLicense,Law I.the
5 following reason(Section]BJ I.S.L5.Business and Professions Cos: ny
city or county
,0 3 which requires.permit to construct,Wer,Improve,demolish,m repair my xeacmre Sq. Ft. Floor Area Valuation
pnor m its iuwnce,dso mquiax the applicant for such permit to file a signed etaliment O
that W is licensed pormant to the provisions of the Cornamafa Licence law(Cbaptcr 9
fmmmeeing with Seems.7Boo)afoiviaian3afd,Box.am Pmfeatimrc Code)rcAPN Number Occas enc Type
that he is exempt thmefrom and are basis fee Ned e allegcxungion.Any violation a P' Y. YP
Section 7031.5 by any.pplicam for a permit subjects Ne applicant to a civil N09V Of S7 / 7 / O
pN ore Nen Eve haab dNlars($500).
mI.aamwncr of Rteproperty.or my employ..with w.gu as Nei...lemsepen..unn. Required Inspections
will do th=work,and the structure is ON intended or offered for We(Ser.7044,Business
and Proratimas Code:The Contractors Lianas law does ON apply to an owner of
property who Wilds N improves thermn,and who does each work himself a though
his own employees.provided that such improvements are rot inrended a offered fee
We.If,however,the Wilding nr impsevcmcm is sold within one yearofcompletior,the
owner-imild will have the burden of proving that he did not Wild or improve fm Wr-
you of Olen).
L O ower of the properly..m exclusively convecting with licensed wntnctas t- ^
same Let the project(See.]Bab,wnei of pend nywho oas Code:)The Cmmacton.dd ✓O
corms law des WE apply e ut owns of presby who Wilda or improvesdmthereon,and
Lwho icin.Law.for such pmjeets with a conuamgq licensed pursent m the Contramfa
license Law.
1 um txemN under S.. .B 9 P C for Nis rcaarm
Owner Data
WORM S COMPENSATION DECLARATION
1 hemby aRrm under penalty of perjury ons:of the following dadmanc s:
❑IMWandwillmainuina Cenifcamof COas IMOlf-inmafor Wekc,i Compete
..tion,as provided for by Section 37W of the Labor Cade,for the perfomuace of the '
work for which this permit is issued.
,KI have W will maintain Werkcr't Compcnwtion Inmeme,as mquircd by Section
3700 of due Labor Cade,for the perlonasec of the,work for which thio pmnit u issued.
My Workee cam�r,, tay and Pocy
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corm.: `IRILi �
i+VmiJ PolicyNO.:7. l'.i'.24A-00
CERTIFLCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becomple ed if the permit is forone hundred dollars(SI W)
in lest.)
1 ccrlify that in the pc.farmance of the work for which this permit is issued,knell
NO employ any person in any munom m as to become subject to the Work..'Compes-
wion Law.of California.Data
Applicant
NOTICE TO APPLICANT IL after making this Certificate of Es'-prion,you should
We.eubjost to Ne Workers Compensation pmvisimm of Ns Labor Cade.you..at
forthwith comply with such provisions N this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
0 Q (hereby aRe^Nat thea it.canurabe-lending agency for the pellet cof
Z
the work for which this permit is issued(Sec.Ms07,Civ,CJ
Lender,Name
> Ieadefs Address
01 amfy thou 1 have read Nis application fud..a that the above halmona en is
9L. Co."I agree to comply with all city and countndte a
y cadmium.a .4laws wing to
z buildmgmensimetioo,and hereby mNmia ent eanutives of this city te mar upon the
CJ Q movememiatad progeny for inspection purposes.
k, Fy (We)agree to save,indemnify and kap harmless the City of Cuper ino against
C) V liabilities,judgmcnta,costs and expenses which rosy in my way accrue agaNM said City
>. W in consequeae of the grbming of this permit.
[. C- APPIACANI'UNDER%LANDS AND WILL COMPLY WITU ALI.NON-POINT
U Z SOURCEREGULATIONS. � _ =1/ /
Sigtuture of AppWer D. {./.
HAZARDOUS
AZA
HAZARDD OUS MATERIALS DISCLOSURE L�/-ro f V
Will
y'te Cupentor!mum Wilding e.chapter
or hurdle lReaNausmnmd Re-roofs
as defined by t25 Cupertino Municipal Code.Chapter 9.12,and the RWth and Safety of Roof
Cade,Section 255JNa)] Type
❑Ver mho
Will'he epplicmlor Imre Wareing.cupmt use equipment or device,which All roofs shall be inspected prior to any roofing material being
emit hasardoos air cormorants ax defined r.by the Bay AAb m
Quality Manageent installed. If a roof is installed without first obtaining an inspection
' District] I aree to remove all new materials for inspection. Applicant
❑Yes WN.
I have read the haysideusmaterials requirements mode,L,upter 695 of the Cali un erstands and will comply with all non point source regulations.
fomes health R Sdmy Crile.Sections 255U5,2551]end 8534.1 understand Nat if Ne
building docs ria currently have a tement,that it is my responsibility,W nitrify se,=Owl
of Ne mpho menu which of a Cmificate of Occusima y.
/fix e1L /'tom[ 3-7—nom Signature of Applicant Date
Owner,or suNon+ed agent Daa
All roof coverings to be Class"B"or better
OFFICE