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01020123 (2) CITY OF CUPERTINO BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: NUILDINGA nRCSS PERMIT NO. O 2 0Z OWNER'S NAME: APPLICAT[ON SUN DATE I'1g)NG: F SAN]FARY NO. CON'I'SOL NO. BUILDING PEIt MIT INFO I p-,.o AMCHI'fliC'I/IiN(ilNlil M: BLIH'i GLECI' PiUSIB MECH rcW l da z5vg IWrobraHuCuinslli,,;lien.cJunJcN'Pi,lrcinARici�p"eremr,n,lneneing Job Description F=CLL with Section'ItgpiDivision 3ofthc Nusine—ad Professions Cdaandmy license a mm Is in roll Ibrce and cl'I'cct. a' a Li ccnsc clans Lic.N TC �3`� Use DECLARATION I J�JBL t• O nRCI{ITECT'SDECLAMATION t g I understand illy pLca"Itall be ailed us Public neords a, / w d o O Licensed Promiu fowl a. OWNER BUILDER DECLARATION u�= I hereby:dhmt Ihat I n empt from the Contract or'v Licenw Law for the t < lidlnwing rmsnn.Perot,, a)u L.I. ..1her. and wefde n l Crete:Anyemu airy ,county ` ad 2 O whirM1 reyu:rcs a peat(In eonslmw4 alcor,improve,h pernit t file repair any.cactus 8. prior mils isswncc,also ayuimxthe applicant for such permit mfileasiennl.utemcnt - Ihatheivlicensed pursuant to the pmviaon%of the contractors Liceme hw(Chapter 9 S9" Ft. FI or Area Valuation commencing with Saloon 7000)of Division 3 or Ill,Itusincesad nProfession,code) I"(be,he is cxvar,Ihcnefirl and the hassle lar the:dleged exemption.Any violation of Smfinn 7071.5 by any applicant for a rental subjects the applicanl to a civil Penalty of not more than five hundred doHaa(5500). APN Number Occupancy Type Cl 1.as owner at the property.or my emph,res with wages as their sole c„mpcnaation. IDa�..eL will Jo the work,and the smucmm is not intended or offered for sale(Sec.70f4. Business and Professions Code:Ile Contractor's License Law dors not apply to an Required Inspections cancer of property Whit hoilds or improves thereon,and who does such work hinivell ,r Ihongh bis own e:nployecs.proluild thal inchitm,nacats l un Intended o ofYamd[of sale.IL however.the building or impowcmm eis sold within one year of nnplecion.the owner—hiker will have the burden of proving that he did nm Wild or impmvc for pmpnse of salt), - ❑1,as m ,r of t •pmpeny,out xclusivdY a,mracting with licensed contractors m construct the pr Sm.7(W.Business acid Professions Cash:)The Contactor'. License 1':w Jr all a Is v,an owner of p openy who builds or impmm,tbemon. and who onl s Ibr eb pnjeew w' a n trach s,)licenced pursuant to the Contract ❑Izmew land .B K P C for this reason lei WOIIKEWS COMP. SAIIONIII!CLAR LION I herby norm under Pen of Perjury one of the following declarations: ❑ I have and will maintain a Ccnifcum of Clawal 1.edl insure linW alon.s Compensation, as provided for by Section 3700 of the Labor Code, for the laerfonnmme of the work for which chis permit is iiia J. ❑I have and old inuinmin Worker's Coml"n,calic howl—aa.m required by Section 37M of the IaWr Calc,for the pctlbnnanm of the walk lo,xhill Ibis peril is sued.My Worker's Compensation Insurance carrier and Policy number arc: Carrinc PolicyNu.: CERI IPICAI'ION OI'F"XENIPIION 1920M WORKERS' CONIPENSAIION INSURANCE (ode cation need not he oa,Iufad if Iba permit is Ibr one handled doll— (gl0K0 nr Its) I many that in the safamunm of the work for which this permit is issued.1 - ,hall not cnapiny any person in tray I yr a,as u:heco:ne suhjcm h,the Wo ka” Compensation Luws of California.Dam Applicant NOUCE'10 APPLICANT:IL after making this Cenificum of Exemption.you should nwoneunjca w the W..kur'n Cour,cosadon Pnwisions of the I.aMn CnJr.you must Q Qm Ibnhwith comply with such pnwldons or Ibis permit shall N Acemed revokal. z2 F ^ CONSTRUCTION LENDING AGENCY ai 7 I only affirm that here is a conoradion lending agency for the verforance of lac work fior which lhls knob is isxnal lSm.7097.Civ.C) . 6. Q Leader's Name 7 Z Lender's Address (..1 Q Irenil'ytbul l hava read this n,lianion; In,an,lud the weave In lotion Ilx Rn t..: cosec ce I rn:nply with n1I city and county nrdinanaes and slam law,relating Q V h,but Jing co a action.and hereby anchorvu¢praunwtive,oOhis city to enter upon the an ve J pm.in 1Int inspection purpn¢s. %1 F •) slim . "Kilda lis and wap I only innu,cityofcall.naagainst 'n City in dgmcn ,Casts xM cxpca h may in anY way antras ugaine wid V Z City in c nen of IM1c gaming his w 1. ^ APVLit VI ' lERSTANI LCOMPLYwirnIALLSION.POINT I E r N' Issued bye -:�P— /�/ki7Jf��['eer Date O/ gm I. Applicant at or [)ate Re-roofs HAZARDOUS NIX] iRIALS DISCLOSURE WI11 the applimin or Insure building occupant tom or h:tndle hwnnlous mamrlal Type Of Roof It,Jdined by Ibu Cal:acra Municipal C .Chapter 9.12,.,,it the Heal,and Safety Calc,Section 25532(a)1 - OYes All roofs shall be inspected prior to any roofing material being installed. Will meappIcl cut ordevim,which If rc f is installed without first obtaining an inspection, I agree to remove mit hanchka,air conmminanas m def incl by the Hoy Arcu Air Quality Management uietdcr all e Is for inspection. Applicant understands and will comply with all n oint s u regulati us. 1 hu c lir tin mnlous la iula rcyuircmcnts under Chapter 6.95 of the Ca domia cal a ffi Safe Cale,Sections 25505,25533 and 25534.I understand that if, chit mga not mmlyhavcamna Ihat mymsponsihill,u,anufythe t'll ,f ten uhi i ems wch I owl ,r to iss..arm at'a Cl nificahe A °c nP y' / Signature of Applicant Date orae All roof coverings to be Class `B" or better OFFICE