00020085 (2) CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: �� ru2-0'0
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ARCI IITF.CrfENGINfEg sin -193 -2012 BULDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
FutO in— I ion? afrnnn Nat 1 am fitheBu under proviuom of Chapin 9(ro Job Description
coded Stttion>OW)ofDivipionlofthe Businessmd Rohuiom Code.eMm
a f7 infullforceudellen./Jpff/�Y�OI GUo)erhevler �e10/see~f
y o uccnll.l�3LWLL+L Co
ng
ups 3 u.v Dam C
ARCHTIF,CTS DELL DECLARATION
i undertone mY Plans Nall W used s public rccads
H
O Licensed professional
¢3_^ OWNER-BUILDER DECLARATION
t-Z C N 1 hereby affirm the,I am exempt from the Contractors License Lew for the
E:s following meson.(Swim 7031.5.Business and Prof ions Cuda:Any city or county
5 m which mquims a permit to construct,alar,improve,demolish,or taped,any seucture in NSq. Ft. Floor Area Valuation
prim to its i...W.Moires The applicam for such peanut m fie a.igmd saumenl
that he is licensed pursuant e provisions of the Con c nofe Liccn¢Law(Chaptm9
(diming iNSection7000)ofDivision3ofNeButimasamiProfessionsCoe)m
NppNNumber _ Occupancy T at he is exempt Therefrom Nasi
efrom ane bs fer the alleged exemption.Any violation a ane 9 _ /S P Y YPe
Salon 7031.5 by any applicant far a«mut subjects Ne epplicanno In.civil penalty of
p1 more Nan fve l uMr4 deollars($51)0).
Las owner ofthe property.nor my empmyeer with wages u Ncir sole compensation. Require ns tions
will de,the work.end Ne,macmm is not immded oroffemd fm We(Sm.701d,Buuncst
and professor,Code:The Cmirwer',License law enter not apply to an owoer,a
property who Wilda or improves thereon,and who does such work himself or through
his own employe,.providW the,such impmvemenu art na intended or directed for
We. -hmveves,the Wilding or improvement it sold within one year of completion,the
r-Wilder coal nava tM burden of proving 51.1 he did nm Wile or improve f«put-
pom of se,We.). /
1, ower of.L So,70property,,H exclusively contracting with IicauW oonlunms t.
concoct the projm apply
o an Business and Professions Code:)The Cmhereon.Lid /1
cense law em na apply je ts widen of progeny who Wilds or improves C---end fir/O
who contracts for cath pmjtta with acwnvutor(s)licensed punuanuo Ne Contradott
licenm law.
1 em exempt under Sa. .B A P C for Nis Hawn
Due
WORKER'S COMPENSATION DECLARATION
I hereby Affirm broader penalty of perjury ore of are following declanlims:
Q I have and will mainuin a Certificate of Consent ro self-insum for WeAcT's Compen-
sation,as provided for by Secure 37W of the Labor Cock,for the performance of the
Mor which This Fermi,is ivucd.
have W will maintain Workers Cam,mounim lmun .as mounted by Sation
3700o1fNc La Wr Code,for Ne perf Icer.of the.,it fm which This pirmil is issued.
My WahyifIr,B sure«c aurin end PolicyvlOj(
Carrier. 9m LL CRRTA Policy
CERTIFICATE OF EXEMPTION FROM
WM 00.KERS'S'
COo,cour lendtu INSURANCE
(Thin setinn need not becwmpleted if the permit in fdronehwMred dollars(3100)
or less.)
Iunify Rest inthe anAamanceoldie
as am.-k for which this gaminisislshall
noemploy any person in any manw ner become cubjat to The Worsen''C Compen-
mtion Laws of Celifomia.Dau
Applies t
N013CETO APPLICANT:If,ahamaking this vi,,imam of Exemption,you no ld
u"
Mehme subject y it Worth ro Coon,or Compensation pmWlona of the IaWt Cade.you mon
forthwith comply with such provisions or Nis permit shot W deemed invoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm'
het them is a coni union lending agency for the performance of
7. the work for which Nis pemti,is issued(Sec.3097,Ci,C.)
4 Lender's Name
> lander,Addinsx '
R71 certify Net 1 have rod Nis upplicstim and sure Jut do Mc infmma,ion is
Oc 0cormet.I agree,to comply with all City and county mdinutas atm note laws nes nng m
t7 building construction.eW hereby euthmise representatives of Nis city to enter upon to
U above-mentioned%aperty fur inspection purposes.
(We)space in save.indemnify and taP ham l"s the City of Cupcnino agaNst
U liabiblies,judgmenu,cosnend expenses whichmey in any was eccsueagaiii.said City
inconsequence of The ratgin,of Nis permit.
APPLICANT UNDI SIt,NDSAND LLCOMPLY WITH ALLNON-POINr
V
SOURCE REG Il
Sigonmre of Applicar for Doc
IT RDOUS MATERIALS DISCLOSURE
Will Neepplicemor fuwm W.Mmiloccupust nwinofhudle hasallous maretial Re-roofs
as defined by the Cupertino Municipal Coda.Chapter 9.11,and the Health and Safely Type of Roof
Code.Satins 25531(.)7 / YP
Oyer
Will The applicant or future Wilding«cupnm use equipment mdevices which All roofs shall be inspected prior to any roofing material being
crust hacomminution,rei air comminution,aw deEved by the Bay Area AG Quality Management installed. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
d Ne h
❑Ya
Ihavemeererdms material.rtyairemenu under Chapter 695 of Ne Cali. un erstands will comply with all non point source regulations.
frond,Health A Safm C e,Satiom 25505.25533 ud 255M.I uMusuvd that if the
building edam nae. t heves mnwLNat it is sur mapondbility in wily Jan eupant
of Jct nryuurne must be sun gni suarce dt a Cmitisyt�c cc
LLQ- Signature of Ap an Date
owner or eu0m : au
All roof coverings to be Class"B"or better
OFFICE