00030040 (2) CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: jy�� 75 00
BUILDINGADDRESS: le ,� pOy,J 14 IWCJ
0,6 -1, �`.114 c Af•I e �( s(/ SANITANY NO, APPLICATION SUBMITTAL DAT
OWNS 'S AME'_ �1 �1/�N�, �/O�A1L ��C NIC CONTROLp
TI' ❑
L11QywAio, CA-
VCHETECTIENGINECRR Y��yj'
BULUING PERM1fIT INFO
�T-N"+ LICENSED CONTRACTOR'S DECLARATION
z o te� I herzby aRrm tw 1 un littered undo pmviaions of Cheper 9(commercing Job Description
Few with5«lion7000)of Divirion3af We Buxincss and Professions Cml[.and mYliccn,e is FtIYI✓�C� eitA�9e
�xs� in r9n rm«wert«tG-1,0 30Sf7.s.�
a Lieenxe
a°u.„ Date
�s RwM� �EWARATION ACJ F!// NA L I1t x{s S0 r 06O
ypnaaundmulb � era
�< �_ /QO� ODD ,tYf �
o° Licensed pmresslmw ,p 4 p I / 'If. S
w= OWNER-BUILDER DECLARATION / 30 000 V �� 1,9/ a `' Al; • � �” r2A 03 O
F i< 1 hereby afl;rh doer I ev exempt from Ne Convector's License Law for IM
dS❑ following....(Section 7031.5,Busmen and Prokuione Cade:Any'city or county
i which requires a permit u co mrum,after.improve,drrmlich,or repair any swctou Sq. Ft. Floor Area Valuation
prim to its issuance,also requires Ne applicant fa such permim w rile uiBmd suternmd ?0
Net he is licensed phumanuo doe p ovisions of the Convacmr's License Law(Chapter 9
(commencing with Section 70007 of Division 3 of rhe Business and Professinm Cards)oApN Number Occupancy Type
tut be is exempt thacfmm ed the basis for the alleged exemption.Any violation of
Section 7031.5 by any appliant for a permit subjects the."It.'I.s civil penalty of 3 5-�, 0 C>
a ileac Nn fi
ave hadncd dollen(5300).
p Las owner of the property,re,my employees with wages as their sale campemation. Required Inspections
will do the work.and Ne tmhctuu is nm I....dadooffrom fm selc(Sec.7014.Business
and Profession,Code,:Tho Convacdur s License law dos norapply to-o rncr d
o
ppery who builds m improver dtereon.W who does such work himmalf or through
his own employers.provided tut such imptavemenv art not intended of offered res
asla.If.however,the Wilding or improvement Is sold within one yrmofmantletion.We
owner-Wilder will have the human of proving that he did not Wild m improve fa For-
pose
I,as ower of the Sm.7 am exclusively coavacting with licensed mostrus i-
cumwa the door
apply
to
Business roperty who Wi Code:)The es than roe's Li-
cense law cats not applyje ts with
of metr who Wilda rs improves tterton,and
who mnsssedsfosuch Projects with amnuudm(.)Licensed pursuant to Ne Convector's -
License law.
O 1 am exempt under Sec. .B&P C for this reason
ower, Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Cenrlty of perjury my of the followingwasiontiom:
I neve and will far b in aturn 37M of the Lit ro Crate.for
res Work<h Compen- C
utim,n provided fm by Sation 3700 of Use Labor Code,fm the pedomuna of the O
work for which this permit is mums
3 1 have and will maimun Workers Compcmuion Insurance,es required by Section
3700 arm Labor Code.for
the performuice of Us,week fm�which
htthis permit u issued.
C Wort3�fi ser!tee lr ieC. aPol c Noand r:
%�T/.�ay�•0�
Carrico_- 1L_ Y
CERTIFICATEOF EXEMPTION FROM W
ORKERS
COMPENSATION INSURANCE
("is nerdrot becomplednd fthePermid '
is fm one hundred Wtlere($100)
or leas.l
I med,the in the perfomunceof the work re which thiapemN is isi1shill
an employ any person in any manner m as on become aubjecr to We woheh(Comprn-
.mion law.of California.Date
Applicam
NOTICE TO APPLICANT:If.after making this Cedifcme of Exemption.you should
Semi subject to the Wortrr's Compensation previsions M ds,Labor Code.you in
foMwith comply with such provisions or this pertdt drall W deemed revoked.
CONSTRUCTION LENDING AGENCY
0 Q (herby alfrrn that there it.conadructimv lading agai famhe Perf--I
Z r Ne wok for which this permit is named(Sec.3097.Civ.C.)
Kilter's Name
(Y > IcMar's Address
I certify dot 1 have read his application and amu the the above information is
�• '� coned 1 agree to comply with 01 city sed county ordinances Ind sure laws relating to
,7Z building mummr. ,and hereby orden.representatives of this city.an. pare dee
U above-memionrd property for inspection purposes.
W (~ (we)agree,to nave,indemnify and keep harmlcaa she City of Cupertino sound
O liabilities,judgrrcnv,msu and apemen which may in any way seems must said City
�+. W in comamrce of Ne,Bundne of this penno.
F a APPLICANT UNDENSTANDS AND WI I.I.COMPLY WI'Ft AIL.NON-POINT
V ,Z SOURCE yRRG-U(Tn/AATIONS.o
Si,..ofApplicanJComn Lir Dim
HAZARDOUS MATERIALS DISCLOSURE a
Will the applicant or future Wilding mcupem store no handle nsraAoua material Re- O
as de0tted by the Cupertino Municipal Code.Chapter 9.12,and dW Health and Sucry T e of Roof
Cady.Section 25532P)7 yP
❑Yrs yN.
Wil the applicant or future Wilding occupant use equipment or cevims which All roofs shall be inspected prior to any roofing material being
chis hvardom au mmmniounu as defined by the Bay Arca Ah Quality Management installed. If a roof is Installed without first obtaining an inspection
Dlanct7 I aree to remove all new materials for inspection. Applicant -
1:1 Yes on
I have sad f hmndous antral.mruiumcnu under Chapter 6,9
of the cat Un erstands and will comply with all non point source regulations.
/ fano Ncalth&Shay Code.Sections 25505,25533 and 25534.I undmund don if rte
Wilding dees,..currently have.taunt.In,it is my responaihility to Emily to mcn am -
oftseuyuircnrnuw'comusdnspno2mu ofa Ccndicadenf Occuporcy.
J-7-4249 Signature of Applicant Date
Owrter m eutwdzed agentLate
All roof coverings to be Class"B"or better
OFFICE