00050048 (2) CITY OF CUPERTINO PERIEUT NO,
BUILDING DIVISION PERMIT CONTRACTORINFORMATION. oo bS�O t I
HUILDINGADDRESS:
� SANITARY NO. APPLICATION SUBMDTAL DATE
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ARCHITECT'/ENGINEER BULDING PERMIT INFO -7777
IU. �lC7Y{•'dC��l• O�S' S
LICEN
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ON
z o ? I hereby aRrm maSED I son co meed t�ndeRr❑n°m„ ornCnaaar 9lpnmm�enemg Job Description
0=1=w with Section'A)00)ofD;vaion3o(the Business and PnMessiom Cade.and my license is
< I,,j in full force and GIT
ob t c
gLicemochi . Lica -T5— �U
- snsrtaI,.�, �.� aa � Su�
Conlrec:it T-L13IAT2
ARCHITECTS DECLARATION
S J I understand mY Dlans aM1.II h uvd u public record.
0
a a o Llcrosed Rofeuioml
OWNErd exempt
m the Contractors
t z a 1 muse.(Sero Nal 1 1. exempt from the Cootru Co :A n c Law for the
'r O following rcawn.terms
a 9031.5.Bua;rcu and Prof iom Cod[:cP city a.achy
3 which require.a pwit to carmen,applicant
improve,demolish, fi repair ed em2eve
prim,.its is,runa.aw rtgd2.Bre.ppl;[.nt rm aucn permit to n[.sigr�.l.2m[nl Sq. FL Floor Area +Valuation
that he is licemed pursuant the provisions of the Contractors License law(C9upur 9
(comsmncingwithSecdo.7")of Division 3 of the Busiauw Professiom Code)., APN Number Oecu T
Nat he is exempt therefrom and Be basis for the alleged!exemption.Any violation ane of p y ype
Section 7031.5 by any appllcat turn permit subjects du epplicannn v civil penalty of
pt mom than rive hundred dollars WWI,
I,axowatofth[progeny,mmyemplo mswimwagema irsolccmnpemwm. Required Inspections
and poohc wmk,and the he Com n nm m2Meds Law
do fm Sala(Sec.o an Baaaa
and enly wz In Code:The Contactor i Liana Ian pas na apply s if owner h
Ed,o nY Ino builds or improves such i and ve does such wotk himself.,o r or through
Ed,own however,
provided Nu such imp I.sold u ere nm inter.f a olden,for
ale.H,M1oweer,Bre building rs;mpmvenrnt ie told within one yeuofniphomlior pm-
owarbuilder will nae the burden of proving that he did oar build m improve for bur-
you of ale.).
1,u ow err of 112 progeny,am exclusively contracting with licensed contractors to
conuruat the proicc,(Sm.'/BN,Business and Professions Code:)The Cantracta's li-
cense law does not apply to an owner of property who builds in improves demon.and
who contracts for such projects with a eommoods)licensed punuwt lone Conlmcim's
License Law.
O 1 am eaempl under Sec. .B&P C for this Rixon
Owner Dae 6
WORKER'S COMPENSATION DECATIONart. LL /
Nic"' 1 hereby aunder penalty of pe 1.,mY LARoa of Bre followin8 declwiau:
1)raK std W;II rlrLntYn aCen;ritalC afe0aelrl la alf-In1Y2 fIX Wark[raf.Orrrpen-
Mofffic
;m,m provided for by Section 3]00 of the Labor Cale,res the ped..of Bu QQ
mk(a which this permit is isssud.
I have W will mvinuin Worker',Compensation Imuswc,a textured by Section
Labor Code,for the perfomunce of the work for which this permit Is isxm1
My Warkeh Compmatian Inxurwe cerrier and Policy be
policy
Cartier. �T�a�T T Ge^iN L1 Policy No.: r����
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This aatne need not becomplered ifthc pcmtit is foronchundreddo11ers(SIM)
Or los.)
1 certify But in the pamfin muecof the wmk for which its.pemtit is issted.l slWl
too employ any pawn in any mann an as a became subject I the Warken'Compcn-
ation Laws of Caifom;a.Dau
Applicant
NOTICE TO APPLICANT:If,ager mvlBng this Certificate of Exemption,you should
,mots subject to me Wotkcrs Compensation provisions of Bre Labor Code.you must
forthwith comply with such pravixions amu pe.iuhall be,dimmed revoked.
CONSTRUCTION LENDING AGENCY
0 Iherebya aim that mere is a construction lending agency for the performance of
z 2 the work for which this hornit is Issued(Sec.3099,C,v.C.)
tw Lendse,Name
lenders Address
fa: 1 Unify that 1 have read this application W awe Thu BIe above infontmtian is
dGroes,.I agree to comply with all city and county oNimand es asue laws 2Wing to
D z building coonmmbn,soul hereby aullurice reprnemulven of IMI city in enter upon me
U C ab at-ountiannd ptopmy for inspection purpcus.
IT, F (We)agree to ave.indemnify and kap handless the City of Cupertino agelnso
C U babilifies,judgments,emu and expenuswhich may in any way accmeagans,said City
;s. W in consequence of the granting of this permit.
[� 11 APPLICAN,UNDER51'ANIIS AND WILT,COMPLY WE I ALL NON,YUIN'f
V � SOURCE REGULATIONS -
s-s•ou yp
Srgnatomal Appicantv
/conectm Dau O DO
HA].kR000S MATERIALS DISCLOSURE
Will bee.ppl;camo,future building occtpanmtmi handle huallons material Re-roofs .
in definnd by the Cupertino Municipal Cosc,Chapter 9.12.and the Ham and Safely T e of Roof
Code.Section 25532(.)^ yp
[I yes ❑Na
Will thc eodions or furore budding.,owl sax equipment or devices which All roofs shall be inspected prior to any roofing material being
emit harudous air conurinantdned an
by the Bay Area An Quahry M ,..l installed. If a roof is Installed without first obtaining an inspection
Diatr;m, x usefi
I agree to remove all new materials for inspection. Applicant
❑Yes 71 NO
I Exam rad Bre haurdou,ma2da,2gtirements under Clape,695 of me Ca- understands and will comply with all non point source regulations.
front 1(cslth&Safety Code,Scrams 25505,25533 and 25534.1 understand that if the
budding does oro cm2ndy nae a¢ren,,that;,is my responsibility to nmdy the mcupenl
�fyr rtyui2nrna wMcn mut h/ ptimumaae ofaCm;ficae MOaupwy.
e�i-4Q a,.,a... S-9-CXR Signature of Applicant Date
Z';;
err aumnmos!agent Dae
All roof coverings to be Class"B"or better
OFFICE