00040114 (2) CITY OF CUPERTINO PERMIT NO,
BUILDING DIVISION PER
MIT CONTRACTOR�1INFORMATION:
BUM °RESS& ^
�fIrON-t.,.vUBM
=ALDK,, 7SANITARY NO
OWNS AME:
NIC CONq'ROLk
YH El
C ,a� 3 — �/7 4 3 0 6
�(, HULDINO PERNII'I'INFO
iRCHITIiCf/IiNGINEER ¢93- 373
0[0
U(J
h�a
N LICENSED CONIBACnd DECLARATION
z o„5 I herby ammr than l an licensed underr provisions of eneq<r 9 umnmencing Job Description
�:EuOi wish Section 7000)of Division]of the Busineasand ( siom��r'mY � /
y in full forte end alfa a sac.N 77
as W V^..• s rJ / -
pate Cmrtracwr ��tutu
f.,.sO ARCHTIECTSDECLARATION � � ..y1.�. W y,
v�yS hind&"tandmyplenaofWW
lbe usaspuhlierecords
IicaneW Pmrreslonsl
c OWNER-BUDDER DECLARATION / l✓"'v
I_,Y 1 hereby am.shat 1 am exempt from the Coeoecwfs License Law for the
sDfollowingrives.(Section7caustrBusinessand Profe"iom Ca de:Anycityoroounry
wmen aquinanpermh On<omtekdtu,improve,demolish,me 2 signedaRmture 5 Ft. Floor Area Valuation
3 pnotoits censedp dwregpim theapplicantfor such Contractors
wfcleuLnedamemem q•
Red he is licensed pursuant the provisions or the Conoectafe Liecna Lew fCheger9 (� l!//I'�/ � t•/ f/
(concenerwirig withi Sortie.70(1 Division 3 of the Business and —,- APNNumber - Occupancy Type
Ws be is exempt Ihmfrom and Ne basis far the AJO W cuticular.Any violmion of
Section 70315 by any applicant fore permit mbjects she applicant tu e civil pemlry of 3 75 y
d Nen five hundred dollars($3110).
pmac Nen
or myamployerewith w.gasass their mleee., do., Required Inspections
will do the work,and Ne swcture it..imendW oroRead for sale(Sec.7004,Be...
and Prof<ssiom Cade:ran,Conmaor'a License Law does.1 apply to an owner a/
property who Wilds or improver thareorr,and who does such wok himself or through ,
Na.....playas,provided Wt such improvemenu are.1 intended as offered far
sale.If however,de,Wilding or improvcncns is sold wirhirr one ycar.fcompIction,the
owner-buildee will have the,burden of covRs,lies he did ries Wild Our improve for par-
,awe of tele.).
❑I,u ower of the,pmpenr,un reclusively contracting with licensed corrosion"to
construct the project(Sec.]OCG,Business and Profeuice s CoLeJ De Cont"ato's Li-
cense raw data not apply to an owner of propcny who Wilds or imgavev thaarrn,end
whaconnew"for such projec"with a onan cso(s)licenced pursue.to the Grearwsols
License
0 1exempt
1 aexempt under 5«. .B k P C for this reason
owner Date2
WORKER'S COMPENSATION DECLARATION
Rm ry,
1 hereby arunder penally of perjuone of the following declarations:
Han .nC will mainWn aC nifimteof Conaanuo calf-Inwm for Workces Camprn- O
tion.is prodded nor by S.Uen]700 of the"bo,Cade.for the Id--Of the O
h part
for which this peun is Issued.
1 have and will nu urau.Worker's Compares ion Iver ems.as required by Section
700af the labor Code,for the perfarmvoc of tie wok for which this permil is issued.
My Workt Y s �Vwranc award PallcY �. JAI
Carrier: Polley FROM
124,
CERTIFICATE OF COMPENSATION
INN FROM WORKERS'
COMPENSATION INSUMNCE
(iiia rection need not W completed if the pemdt is forone hevAcd delle"(5100)
Or less.)
)certify that inthe arY...a' of the work for which thispemdt is issued)shell
not employ any person in any manner so as to Wenner subject In tie Workcra'COmpen-
satian Lows of California.Date
Applicant
NOTICE TO APPLICANT:If,afar making this Certificate of Exemption,you should
become subject to the Workefs Compensation provisions of the Labor Code,yw must
faMwith comply with such previsions o this permit shelf be deemed revoked.
CONSTRUCTION LENDING AGENCY
Q Q Ihereby afirro Nm them is u connrection lending agency for the urfroorni of
Z r New k for which this pesmil is issued(Sec.3097,Civ.C.)
4 Lcndels Name
7 Lenders Address
�] 1 anify that I have read thir application anal sedn tN1 the above inforr ion is
0. 12 e....I agree to counplY with ell city and ceumy ordimncns and sue laws aleting hi
5 Z building construction,and hereby audwnire mprcsentelives or this city to enter upon the
V eWvementi...d property for inspection purposes, -
W F. (We)agree to save,indemnify and keep humle"the City of Cupertino against
() liabilities,judgmenu,cmM and expenses which not in any way accme egeion said City
y L7 in conn trene<of to granting of this permit.
E+ ly APPLICANT UNDF CI'ANOS pNIy WILL COMPLY WITH ALL NON POINT
S(IUHC�Pc}(yiGU TIa Vg.
U ,V s
Sigmture of Aff,liql1niCaurectur
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding cccupanuwre or handle har4Naus materiel Re-roofs
as defined by ted Cupertino Municipal Cede,Chapter 9.12.and oW Health and Safety Type of Roof
Cole,Section 255P2(A7
❑Yea e�O
Will the applicant or future Wilding occapenl use equipmem or devices which All roofs shall be inspected prior to an roofing material being
emit lneaWom atr contrunimnta as defined by the Bay Ams AB Quality Maragement installed. If a roof is Installed without first obtaining an inspection
Diaoict7 VAK� I agree to remove all new materials for inspection. Applicant
Ya
Iha read the harudous autenals aqui¢..a ander Chager6e5 afthe Cali. un ars nd$ d will comply with all non point source regulations.
!emir Health k Safety Cade,Sechom 25505,25331 and 25514.1 understand that if
ft c j
code +r co °e thvis is my asponsiMlirywnwify occas t z
of the rtqui ilei xoxo be mwomeneeorailabl'camn J,h6G.,O7/,r. '
a �s� N Signature of pplicant Date
Owner.authode <nt
Data
All roof coverings to be Class"B"or better
OFFICE