00060039 (2) CITY OF CUPERTINO PERMrr No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDR&SS: 0�J �� -
/J ��sle L SANITARY N[. APPLICATION SUBMITTAL DAT
OWNf;R"'OMIa G/• ��f�/'///ryO /%U� /� P�fJL/
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HCHI'fECT/ENGI'EER il) �D C Y_, /,�/ �✓�/F7 RULDING PERMIT INFO
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LICENSED CONTRACrOR'S DECLARATION
O h'= I hereby al<rm that 1 and liccriaed under provisiom of Chat 9(moth, Job Description
roz 0. with Sarion]000)ofDividon3of the BuxinceaaW Profeniom Code,atd myli<enu is
d rc u Q in mil force and cRUL
a O Littnae u Li<.
+�3 a y Dam Convector
ARCHITECTDECLARATION
'S
se sty" IUMenuM mypWsslWl ba upubiic records f/
3Y Cli v //
i`n. Lmmnacd ProfesakrrW
^_y OWNER-RD[AER DECLARATION
C z r 1 hcnby affirm that I am exempt from the Contractors License Law for the
s C Pollowing reason.(Section 7031.5.Business and PmRuiore Cade:Any city W county
i3 wmchtaquucs is permit to c.ct,dter,improve,demolish,or mush any auucnire Sq. Ft. Floor Area Valuation
prior to in i! so mgmrta the applicant for such permit m tilt a algm5 atescmcnt / a,��
diel he is licensed punu me pmv7ncs of me Coneacmra License Law(CWger9 / b Q w V N/
immnumingwim Smden] Division 3 e(me Bualan and Pmlenionni ar push Number Occupancy Type
that he is coment thacfrom aW du 'a for dm alleged exemption.Any violation of C P Y Yp
ction]031.5 by any applicant fon a pe t subjects LW applicant to.civil penalty of 3✓ -� O���i
nm a'.Mncd dollen f55
1,as owner Orme propeny.m myemployee.with wages, chair talc eampenaatine, Required Inspections
will do the..,it,and me.uuaure is trot intended or offered for sale(Sec.1(K4.Buairu.a
anal Pmfessirru Cade:The Constraint's Lianu taw does nor apply to an owner of
ptopcny wed Wilds or improve.thereon.real who does rush wink himself or through
his own employees,pmvidW mat such improvements am nal intended m effected for
sale.If,however,the Wilding or improvement is old within One year of completion,the
owrcr-WIdCI will have rbe Write.of proving that he did mr,Wild ar improve for pear
you of sale.),
1,m owns ej the property,am Border.
and coneating with )The Ctonvamon to
construct the es con (Sec.o014,Busum aW Py wine m Cede:)The at then la's ted sty
wholaw don int apply je an owner of property wed Wilds rs implavea Merton,end
who converts for such projccn with a conrndor(e)licensed punuem m the GonwctWa /
Licenrc law.
❑1 atn exempt under Sa. .B g:P C for this iwon
Owner Dam O
WORKER'S COMPENSATION DECLARATION
1 Wreby.1 rm under penalty of perjury on<of he following shelso ion:
-ve and will maintain aCcm scatcu(Comenuo se, -so-for Wmice.Compero
tion,as provided No by Section 3700 of Ne Labor Cade,for the pcnfomuiRe of'be
it for which this pemrit is issued.
have and will maintain Workers Compensation Insurance,in requited by Section
W ache Labor Code,fm the peHomrance of dm wort far which this permit is insured.
My Woh n Land Policyn 7
Gnicc �PolicY No: /
CERTIFICATE OF EXEMPr10N FROM ORKERS'
COMPENSATION INSURANCE
(Thur.Onion need not be completed if the permit is femme huWmd dollen(3100)
or bear.)
1 certify that in in.perf mes.of the wink for which this pemast is iaaued.I al
nor employ any person in any menncr ao as to Wcnme suhjccr to thc Woheti CmuPcn-
cation lawn of Ca iform..Data _
Applicant
NOTICE TO APPLICANT.If,dor making mi.Cmificare of Eacmpdon,you should
become subject to the Workers Compenntion govisiom of me Labor Cade,you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
pI Wrtby affirm doing them is a construction lending agency for the pefomunceOF
Z y me work for which this pamir is issued(Sec.3097,Civ.C.)
F.s r Lenders Name
IY I feeders Address
f� 1 certify that 1 have mad this application and sum that me above infomutim is
0. = mrrat.l agnc to comply with all city and county ordinatva and some laws relating to
:;;) Z. Wildinrgmesrris-tion,red hereby,mouraire neprcunruiva of mistily tomer upon the
U Q abovc-mentioned pmpeny NO inspection puspues.
Lra P (We)agree,m nave,indemnify and amp hasmlcsn the City of Cupertino against
U Iubllldu,)udgmen,met,aW espcmea whichnuy in any way ac me sonar said City
} W in emscqueae of the granting of this pemdt.
f"t 0" APPLICANT UNDERSTANDS AND W ILL.COMPLY WI'I ALL.NON1101Nr
SOURCHR IA'II S.
z / %W�5* 61701D
Sig..o1A arV muector Dam
a HA RDOUS MATERIALS DISCLOSURE
WilithcrrmlicantorfuiumNildingmmpemsmRorhaO cha"ousmawHal Re-roofs
u dchmG by the Cupertino Municipl Cede.CWpmn 9.12,red me Halm and Safety Type of Roof
code.saran ns3zatt YP
❑Yet ❑No All roofs shall be inspected prior to any roofing material being
Will ted applicant or future Wilding occupant use equipment m device which
emit hvam
ardous air contaminants as defined by mArm e Bey AAir Quality Management installed. If a roof is Installed without first obtaining an inspection
Diavictl I a ree to remove all new materials for inspection. Applicant
C3Y. Fl
I have mad the hanrdoes materials mquitemcnn under Chapter 6.95 of du Cali- Un Ors anill comply with all non point source regulations.
'.Health R Safety Code.Sadao 25505.M533 and 25534.1 idvsund that if the /I g• /r/a-�/�
W'ddingdasnd cusrtndY MvcamnanL that it is mY rnpmsibilirymngify the oaupant ` /J �-_7 r0
of the mquimmane which mean be met prim m instance of a Ccnificem Of(k<upwuy. a t
Signature of Applicant Date
Owner or euthonized agent Dam
All roof coverings to be Class"B"or better
OFFICE