00020059 (2) CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR4,NFORMATION: �0�rO Q�
BUILDING ADDRESS: /J
�/ C,101- I (//y/���QlL/D•�/t`lr SANITARY NO APPLICATION SUBMITTAL DATE
O NER'SN ME: Jvla/'EN// lira f/�• &zl A /dbagit/S Ale NIC CONTROL#
1 0 ( Z - s NaywaVrd , 64 9yst/S/�2 ❑
ARCHITECT/ENGINEER
BULDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
z o v= I hereby aRrm Ciro 1 an littmd udu Provision of ChaIM 9(mnmercing Job Description
=tw with Sation 70007 afDivision3of theBmincss end Profes,iwu Cole,end lianx is
p< infuBfinee� alesh
A,0/ e��r�f sogQtoesy�6
3 LL oar convermr 1 11)oP/pLc6are ,�eA01/6 y� a
ARCNTfECr'S DECLARATION
1 understand my plans Nell W tied as public records
d¢FO
a. ° Licmred Proressioml
Q OWNER-BUILDER DECLARATION
1 hereby affirm shat 1 em"<mpt from the Conuecmr's License Law for the
x❑ following reams.(Section 7031.5,emineu and Prof ion Code:Any city m munty
w t-m which mr,uires a permit m amrste,".a].'imprvvc.dametim,or neper,any enaemx S Ft. Floor Area Valu t'
prim to its issumm,al'."mrvs dt,.,Iicmtfm,w,h permit m fleasignadrum
scrnaq G
due he is liemmul pursuant to me Provisions of he con"c"h Licenx Law(Chap"9
Emoner.em,with Semon ID00)of Divisiort 3.f the Business and 9ofassimu Cade)" APN Number Occupancy
WI he is emml therefrom and W haeis for the alleged exemption Any violate.of P Y Type
Sedan 7031.5 by my appbram fm a Permit Whites the applicant to a civil penalty of
not more than five hundred dollam($300).
❑I,unwnerarthePr.xdr..rmremPloy"s withw.g<,athmrmlemmpcmmu.n, Required Inspections
will doW work.end,iTh.Co..timcdedmoe,doe, on apply 7014..1a
end en,whiore Code:The v.therm.,
and w law doer w apply s lf owner of
pmpmy who build,w improves thereon,and who dos such wntr deed or or through
N.......loyees,Provided Wt such impmvrold within ere no Intruded a.(fared for
ole.ILhoweverW Wil dingor ienof hams i,holdddt ywofmprove for the
rbuild"will have W burden of govin8 that he did not Wild or improve for pur-
poxofssla.j.
I,an owner of the Property,and"elusively converting with licensed contrenon to
moment W projat(Sm.7044,Business and Professions Codc:)The Conummra Li
cense law does.t apply to an owner of popery who Wilds or improves deaeoo,and
who c. aw.for such projau with.c.vacmrt,)liccnxd puouam to the C.nvutor, /�/O
Licenx Law.
❑I am emmpt under Sec. .B St P C for this reason
Owns Data O
WORKER'S COMPENSATION DECLARATION
1 Wmby affirm under penalty of perjury One of the following dalemtioa:
❑Ihaveandwilloaimm.a Cmir..of Coaenuoxfinmmfwwo cesCompere
vti.e.as Provided for by S«don 3700 of me Labor Code,for the pn..O of the
w=which Nil Permit i,issued.
have end will maintain Workers Com amsetion Imurnme,a tamed by SWion
37M.f the Labor Cade,for the perfomunce Dime work for which this permit is issued.
My Wm¢���Campc see In uranee cam"and Policy
Ceeeic i_.SE( CI �e _PoIiN FROM
_
CERTIFlCATE OF EXEMPTION FRAM WORKERS'
COMPENSATION INSURANCE
(This xcti.n need not bccomPletnd iftW pemdt is laronehundeed dopers(3100) ,
or less.l
1 mrily that in W performanceoftha work for which this permit is issued,l shall
not employ any Person in any manner w as to become entice to W Wmkers'Cobol—
smion Laws of California.Dae
Applicant
NOTICE TO APPLICANT:If,after making this Cerif wo of Emmpu.,you should
bee..wibjatrn Ne WmW1 Compenati.provisions of the Labor Code,you must
roMwi b mmplr with such movimom or this .It shall W deemed revol d.
CONSTRUCTION LENDING AGENCY
Q 0 Ihereby alf.Wl Wrt ise enesoocuon Imetur agency for the perfuneu.e of
Z Ne work for which this Penn"is issued(Sean 3097.Civ.C.)
E., larders Name
7 faders Address
t4I1 certify Wuth
t I neve read this application m state at the above information is
91. zmumt.I agree co
e. oply wire JI city and c.my.Ntro iand,uv law.rebeing la
a Z Wilding construction,and lummy authorize mprexnwives of this City to mer uponW
U Q mwv<-reemioncd ImIseny for inspection purposes. _
CL E„ (W<)agree on xv<,indemnify and kap Enter].th<City of C.,mi.against
0 C.7 Ii,HIu",judgmcnu.mas npenxs which may in any we,acrueageinst said City
�e Ind n consequence of the granting of this Permit.
IAPYLICANT UNDERS' DS ANU WII OMPLY WI TH ALL NON-IYANT
71 C..7 ^ SOURCE REGULA ri(
_
l2/00
SignammulAheaneC x 4
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H S
MATERIALS DISCLOSURE
Will Wepplicant.,future building ormWt stmeor handle hanaN.s material Re-roofs
as defind by aha Cuprnino Municipal Code,Chapxr 9.12,anal the Health ad Safety T e of Roof
Codr,Salm.23531W). --II/ YP
Y<x
Will the mpheaneorfnmrehuildingerr.p.ntmemItty rnt.1desk"whieh All roofs shall be inspected priorwithout
any roofing material being
man herniations air moumitwu a defined by W Bey Arca AU Qumiry Management
installed. If a root is Installed without first obtaining an inspection
District? C.Tv!/ I agree to remove all new materials for inspection. Applicant
❑Ya g
Iha redth haaardnamatdm,regaimrnmaon&,clumor695orthecmi- understand, nd will comply with all non point source regulations.
ramie Hulth B Safety Code.Samosa 25505,25533 and 25530.I understand that tf star
building doeanm eta dy heveemnanr thin it is mY respomibilirymmtay dm scupant y
.f W require h must t prim m iemanee of a Cmffi y� f Oc perry
1 Signature of A ' ant Date
Owncror eutho est e
All roof coverings to be Class"B"or better
OFFICE