00040026 (2) CITY OF CUPERTINO PERN191,10.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0 bc
BUILDINGA D0.HSS:
gANRARY NO. APPLICATION SUBh AL DATE
�t fJI DG 12`^J I Fk N , 11JG �;'A '
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AItCHIl1iLT/ENfINEEN IULDING PERMIT INFO
retu
ovK�t wlaVl PI'aG{7 �i60 fit1`4 ' IOOCD
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Iv~' LICENSED CON7BAC1'OR'S DECLARATION
z O v I Meby affirm Nat 1 w liceru.d under yovisions of Cluptt 9(«mmeneing lob Description
°�-° 1�5
m withSection7t3(p)afDiviSionJofNeBminessandRoh imCode, myli«nu is G• .r�a G
gxf� imm�roroa.aert«l. p � y(�,� gO�w{�. 1y�
sxcwu u_�u..a 1 r �j /y
un 3 u f- Dete Cnnuacmr ^ Gl CJ I �,y'it core, �/t�l`�,
un u C" RCNRECTS DECLARATIO
5u�y 1 understand my plain shall W used as public rcwrds �V
LL <5 {gyp /I�,ktrlA� el✓ ilUleSa
'M'0
Licensed pmfeaelo ad
u =y OWNER-BUILDER DECLARATION
C Z a 1 hereby aKmr that 1 am exempt from On Conuactoh License taw for Ne
dm G following mason.(Suction 70315.Business and Prefeasions Cade:Any city«county
w which rammos a permit an constiva,Wer.improve,d.moliah,w repair any mucnuc S Ft. Floor Area Valva 'on
prim m its;ssuence,also rtquims me applicant for such portion to file a signed au¢mem q'�� p O
DO
that he is licensed pwsuant to the pmviaions of itis Convaaors License taw(Chapter 9
(cotw.weing with Section7000)of Divisim,3.f the Boniness and PrafesSiorn Cade)or ApN umber Occupancy Type that he is m,aw,therefrom and the basis for the alleged exemption.Any violation of / N ®,` P Y YP 07
Section 7031.5 by any applicant for a permit mbjmts the applicant to a civil penalty of (p �/
a mom Nan five hundred dollus(x500).
Lasnwncrofftpropeny.MMYwPloy«swiNwage mu kaoleeampetuaion. Required Inspections
will do thework,and the atmcorm is not intended or offered tarsale(Sec.71144,Business
and Professions Code:TW CWt acer.Lt..taw dm ata apply to an owner a
m
propy who Wilds or impsova thereon,and wed does such wart himself or mems
his own employees,provided Bus such improvements w not intended a off.ad fill
We If,however:the Wilding An improvement is laid within one yearaf completion,rhe
pwnerW ilder will have the Widen of proving that he did ata Wild or improve fellow-
oscafWs.).
❑1,as owner of the property,w exclusively convecting with licensed come mas to
construct the project(See 70x4.Business and Profeuinm Code)The Convector's Li-
sense law does ret apply to an owner of property who builda An improvea thereon,and
who contracts for mch poicera with a convador(D licensed pursuant on the Contractors
License law.
❑l w exempt under Sec. .B&P C for Nis mason
Owner Data
WORKER'S COMPENSATION DECLARATION O
1 hereby a/(w ordtt penalty of mfC one of the following declwtiom:
I Was and will marnoineCcni3sma7M of me abor Cad1. imure forthe Wahcra Comp en
tion,as provided f«by Section 3700 of Ne Labor Code,for the petfarmatwa of the
k f which Nil pewit is issued.
[�j�ve and will mainuin Workers Compensation Insurance,as rtaumil by Section
3700of the taba Code,fn On performance of the work for which Nil p.rtnn is iamd.
My Work aCpmpensetion lnsu c.command Polity nuroblrarVr M1111
Garner: Policy No.: ``II
F,MPr10N FROM wO0.KERS'
A ON INSURANCE
( s:Wia tf pcmuti5roronchuadreddonars(SIW)
orlem" I s
IcenifythathimepeAo.eofth workforw„ichthispetmi.isissued.lahW
n«employ any person in any manner m u ro become subject to itis Wurkcn'Compcn-
lion Laws of Celifomia.Data
Appli[ml
NOome TOAPPLICANT.IL Co making.his provisions
of mExemption,youuWUM
become subject ro dw Worriers Compensation pmvit mai of Na tabor Cade,you most
forthwith comply with ouch provisions m Nis permit shall M Jarred revoked. _
CONSTRUCTION LENDING AGENCY
I hereby affirm Out them is a timawcmn lending agency for dw peff.minu a of
r� N the work for which Nis pewit is issued(Sec.3097,Civ.C.)
Ea Undoes Name
(,( j LandesAdde,
ryI I-•1 I certify than 1 have read Ns application..it..,..list Or aMva Of.d.is
IS .1.1 all se to comply with all city std county odhunces and some laws mining an
Z building corrowtion,not bemehymustrice repremnoweadis city to enterupon the
V O movs-roenllpned property for inspection purposes.
4s. Fr (loe)allies to lova indemnify and k«p„umlea.Ne City or Copenino against
O () liabilities,jndgm.no,cosu and expenses which may in any way a sense against said City
�.•. GT.7 in emilax oetn.of the B.dng of Nil permit.
1. 0. APPLICANT UNDERS'IA NILS AND WILL COMPLY WI'1'I1 ALI.NON-POI N
SOUICI RFCUTAT ONS.
C,7 z Sig^auh of ApplicantlContncmr D.
H RDOUS MATERIALS DISCLOSURE
Will Bc.,litan,.forum Wilding occupms in.ahandle harardous material Re-roofs
as d.fined by the Cupertino Munic/ipal ends,Chapter 9.12,not me Health and Safely Type of Roof
Code,Section 255321a)7 d YP
❑Yes ❑
Will.heapplicant or future building attupml use.quipmenl or devices which All roofs shall be inspected prior to any roofing, material being
m ❑it„ardousaircmumouronons dlbytheBayAreaAirQualityManagement installed. If a roof is Installed without first obtaining an inspection
i”? I agree to remove all new materials for inspection. Applicant
�
eY<s g
r 1 him.laded h admnmatenarm9 immentiwd rGWp th.95afN
Cdi understands and will comply with all non point source regulations.
rami, bolds A Safety Code,Sections 25505,25533 aid 25534.l understand Nat it the
buildingdoeanac tmn0yhaveatenun omit;amyre5ponsibituymo fyth. .pant
.fthe ���/j t prior issuance of a Ccm l t yam,
1C 7h',w 1 i1� /1/1 Signature of Applicant Date
�aaT:e�'gent tyue•��
All roof coverings to be Class"B"or better
OFFICE