00050008 (2) CITY OF CUPERTINO ` ;a" `' PERMITNO.
Ituamrvc.lavtsfoN PERMIT CONTRACTOR INEORMATIO,N:, �O �DO�
BUILDING ADDRF_SS:
{ `lc)"I A Ai�te 6,lo-gs, SANITARY NO. APPLICATION SUBMfITAl DAT
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ARCUITECTGINEER CKV4V0+(r( /A• 9KO(?
9ULDING PERMIT INFO
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LICENSED Liven CONTRACTORS DECLARATION
P = 1 hereby alfnn Nar 1 am licensed under provisions of Chapter 9!commencing Job Description
�_HB with Section 7000)of Division3of the Business and Rofcssions Cak:,aM mYlimnu i. l a�_
in Nil n a Cie andCRcn. VV �U^V •^•\s
u Date Clan Lic.N ,S
i5 3 u.
Date—
On
O s ARCHITECTS DECLARATION
i y I understand my Plans"I tine used ss Public reads
s Y
alicemd Rofeoiow
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OWNER-BIJILDERfrom
DECLARATION
H r a r M1cnby.(Sinn that I am exempt from she CoeranCo License Lew for the
f H c following t<eaon.(Section 7031.5.Boioess and ove.de io demolish.
Cale:Any city a county
which aquina n permit re conxwm,eller,improve demolish,or spur any suement Sq.Ft. Floor Area Valuation
primroits issuance,dsorequire the anon,of for suchpeontofile.signed mtamem m.,a
that he is licensed punwm m the providons of the Contr¢ob License 4w(Chapter 9 Q
(<mm�aane;ngw;utsationT000)nrDivi9im13orm<Buaia...wPror<a.inmcnee)m APN Number occupancy Type
Lou ha is exempt benrmm w N
the basis fa n auegdem
e. prinn.Any a'Wanon of P Y YP
Salon]0)13 hY any apphraII for a pemtir subjau Nc applicant to a civil pewty.( 3s� / O
mon then f ve Wndrtd dollars 1s300).
as.wnanrweprnp<nyenrmr<mgnya9wimw.g<9.,theiranlecnmpelaanPu. Required Inspections
":,=of
I dothc wmk and Neewnorc is nm imertdcd moRerd fm We(Sa.701N,Budav
and Professiom Code:The Contractor License Law docs nes apply to an owner of
property who builds or improves runner,W who does such work himself or through
his own employccs,provided that such impoveme.0 ere not intended or offered for
We.If,howenr.the building or improvement is cold within one year of completion,the
wsom W ilder will have the WNcn of proving that he did nM build or improve for parr-
pose.fwa).
I,an owns of the property,am exclusively contacts,with licensed contractors in
commuct the mi.,(Ses.Ilona,Business and Profeuiom Code:)M Comramors Li.
come raw dee.not apply in an owner of property wW Wllda or improves thereon,and
wllo contacts for such projects with is comm orfs)licensed Inundto the Ccmarcual
Leen.law.
❑1nnoCiocmiptunndeerr Se.� � •. =,- .BAPPc Ioorrthu'rnccurs
ownerar- "^""w`T"�'^ D.rcN
Wm under
COMPENSATION DECLARATION
I hcnbY affirm under pcwty of perjury We of the following declwtioru:
Ihavc.ndided for
action 37 te of Consabor Coca.mrcfa eft Comp the /
weak!as provided fPe mi Seton 31110 of the Labor Code,fm rhe perfonwrce of the
work for which thisPermitis loud. T1
❑1 have end will ons,for Wnhcfa Camp ofthe n Imurowe,u raptured by Salad
37fl0of Ne faWr Code,to Ne perfomurrec ofthe work fw which this person isioud.
My wnrkd'sLsppyn]yon Ipsnrance canis and Policy n.mher�e'.//9 2 �1
Carrico 1�Cll B(J(V Policy No.: W l• B B. /
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This second need not becmnpletd clubs permit is fritone hundred dollen(5100)
or less.)
1 certify that;.the perfonnarlceid the wmk for which his pemtt is issued.I dull
Wt employ any person in any meaner w a9 to become subjar to the workers'CumPen-
,union laws of Cdifomia.One
Applicant
NOTICE TO APPLICANT:If,after making this Canifcare of Eae ilmon,Yon misold
become subject to the Workers Compammon Provisions of the Labor Code,yen must
forthwith comply with such provisions in this permit shall be damd nicked.
CONSTRUCTION LENDING AGENCY
Q I hereby affirm that them is a cootructon lending agency for perfomunce of
the wmk for which this permit is issued(Ser.XW7,Cis C.)
Lenders Name
�a > lender's Address
LT7 I tarot,Nat I base teed this application and min,that she shove infomuton is
d carer.I.gra to comply with all city and county ordiwtcn and we laws noting to
7 Wilding ConsvuNon.and hemby authorize rcpresenrativa of this city to enter upon due
V C abovementioned property for inspection purposes.
W E. (We)agree to wive.indemnify and keep humlas the City of Cupertino.,most
V Ilabililies,jodgmenu,cost.mA expenna which may in any way tw.ea,dnat said City
k71o co.nquenee of Ne gone,of this permit.
1. - I A
APPLICANT UNDERS' NDS AND WILL COMPLY WI'1'It ALL NON-POINT
2 '
U Z SOIIRCB RFCULA'1'ION: `
SiBrwarsofAWhcan✓Conuenm
HAZARDOUS MATERIALS DISCLOSURE
Will IN,applicant or future Wilding occupant store or handle haruNous mmaid Re-roofs
as defined by the Cupenino Municipal Code,Chapter 9.12,and the Hcahh and Safety Type of Roof
Code,Section 25532(.)7 YP
El yes
Will Ne applicant or fumes Wilding acupent use equipmem or devices which All roofs shall be inspected prior to any roofing material being
omms air conwniums as defined by the Bay An.Air Quality ha Management .installed. If a roof is installed without first obtaining an inspection
'strict? �,�/ I a ree to remove all new materials for inspection. Applicant
❑Yes xraO
Ib..e read dre hnaroumer
ds nids mloVmmentrutWu Chapter 695 oothe Cali- un erstands and will comply with all non point source regulations.
AWr u Hash a Safety Code,Sat.25505,25533 and 23534.I utldersuM that if the
building does tea currently have a reason.that it is my m,morbility to notify the occopmt
2Lfp�rc�yuircmcAuwhich mw,W= Ct to rsweae ofa Ccmfcnt fl2cupency.
,.may . swot! Signature of Applicant Date
Owner or authorized agent Dau
All roof coverings to be Class"B"or better
OFFICE