00060190 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
EUILDING ADDRISS: PERMIT NO.
OWNI 'S 'AM1IE: AI'I'LICA❑ NSUB DAfE
OO,
PITON ' SANITARYNO. CON'IROLNO.
-.57,99— — A-
OC! ARCHI'I ECDENGINFER: RUEADING P1110,11 'INFO
w00 BLDGI,LECT PLUMB MECII
y6v
z y LICENSED COM'RACTOKS DECLARATION Job DetiCl'Ip(lon -
_ 1 hereby dnrm nitro I am of,helicensed airs,,provisions of Chapter 9(commencing
nse
`yt J with Section and of Division Janne llusine,xotW PoffeseionsCWavnJ Iry license
d eci.w u in full force and eRect.
O a U I)a,c Clas I.ie.r
w 3 a N Dat, Genrrader
ARCHITECT'S DECLARATION
1 undersand my plam,ball be used.m Public records
�/i 0 \ w
e,%po LiccnscJ I'nffecsin°W
owner-excu"t a ued,C..ADON
w— 1 hcrehy u(Sell that 1 1 en... yon.the Cantruc Ccs I,imnw Law fm'the
C=a lobnh ectu i.Icrou, ,91oilurua al fidw,c...... Crdo.Any city,, ure
`ZO whJ y fK n t t 'll r. P J rh p Y;r um
w C e prior 1 t,i,,umee,rJiq,,,dc,tit I11'r f ou,neir ximito,M 6ned nalculcm
thane, licensed' rt to the p s ifth cut fir.License Law(Chapter 9 Sq. Ft. Floor Area Valuation
(onmmnc ng with Section 70W)of Diwkioa 1 of the business and Profession,Code)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section]Ili IS by any applicant fm a pemnit subjectx the applicant no a civil Penalty
of nm mare than pit,Wrdrxd d.11.(5510). APN Number Occupancy Type
❑I,as owner of the property.or my employees with wages as their sole compemation,
will do the work,and the suucmrc is not intended ar offered for sale IScc."I(ni.
0mlmesx ani Pr..fic,ne,wee:'rhe Commnmr,License Law does not apply ,,an Required Inspections
owner of prol,cny Who builds or Improves thereon,and who docs such work hiinselt
tgh I'' ofs y :. I d 11 1 1 ',m t' tline tiled fir
the II I .Ir lou ti n 'Ilmg - tis. Il '1 ye: n1
rill to rb IU 11Lo,di b l ling ho l did 'build r
�y p for err -tr ).
�wner of the property.T ani exclusively commetlng with We:)Th commenua to
nsns et the project(Seq. to
Business and erty ho to ild,o, The Commcmr's
License co arcs not apply m un els w of progeny who lwilds nemimprove,thereon.
and who cmmm�s for such pmjms with a cantmmoBs)IirenscA Im„uam to,M1c
Commcmr's License Law.
❑1 um n pt under Sec .N d P C Fordo,rcnon
L
ownr Uulc ATION O
WO ER's C)MI'IiNSAIION DECLAR
I hereby allirnn under malty til M Jury Inc nnhe following dedamtina:
❑ I halve and wall n nintain a CeNitleate of Cometh to_self-mean or Worker's
Cnmpunoulon, as Por,ded li,r by Seminn 1700 at the Lahnr Code, to, dor
perlimnuncu of the work lir which this Pnnilt is issued,
D I have and will maintain Worker's Cogen,ont n Immou c,as r,yuiued Iny Section
3100 of the Labor Code.for,he perio ne nce of the work for which this perm➢is
issued.My Worker's Compensation[mumne,,artier and Policy number one:
Carrier: Pettey No.:
CERTIFICATION OIr FMislITION FROM WORKERS'
COMPENSATION INSURANCE
grins section need not be completed If the Permit is for one hundred dollar,
(S 100)or less
1 artily that in lite perfonomae A lie wok or whid,this permit Ls su,],I
,hull nut employ any pe.Snn is wry mm�non,ao xs to become subject to one Workers
Compcnsmion Laws A Calif..ri,Dam
Applient
NOTICE 10 APPLICANT:IL after nwking,his Cenilicum or Exemption.Yo"xlo eld
heconm aunjed m the Workers Cnmpeamtion provision fir the Labor Code.Yen nod
O limhw'ith comply with such provision,or this permit 11'a11 be deemed revoked. -
FCONSTRUCTION LENDING AGENCY
„1 1 hereby affirm that the,is a construction lending agency for the Performance
lithe work for which this permit is issued(Sec.3110.Civ.C.)
Ls Q Lender's Name
.= C) Ceroids Address
C.1 P I I a,na,that I hove read i,1is ilY and On and stare the,,a above lie,,Jin.is ('
Lz. F ,omOet.:;:build
I agree',,comply with all city and c repo ontativees and gate Iowa enter
upoo _
Q r, u.buildingsoatine'iooper,,hereby
amutho...i repicsenmtivaol',his cnymcnmr upon
�y rQ the nhnvcnmmlonexl pmpcny rnr 111 adinn e'.
91y
I,y py e"joul nemsovc.auric teal,ke.'pbnmyin the way rCuleninu al ino
IiLd
Z Cil,Mics,judgmmnts.cows:fid sponse,which miry In xny war accrue ugwnu.vain
f) ,� City in umaynemn of the 6mmlng Initis permit. T
DO ANT UND STAND'. ND WILL COMPLY WITH ALLNON POINT Issued by: Dale V
SOU 2REGUL S.
Sig App is Contredor Date Re-roofs
AZARDOUS NISHIRBMS DISCLOSURE
t Will the applicant or future Wilding Occupant quite orWhole havallousmarcrial Type of Roof
its defined by the Cupertino MuniciNl Crede.Chapter 9.12.and the Health and Safety
Cale,Satin.25512(a)^
11 yes - ' DNo All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future bnEdmgoccupant meequipment ordevices which If a roof is installed without first obtaining an inspection, I agree to remove
roll hemrdons air contaminants as defined by the Huy Are,An Quality Munagcmmnt
oN,idv all new materials for inspection. Applicant understands and will comply with
El)'a 13 No . all non-point source regulations.
1 have read Ne hmurdous mmeriuls requirements under Chapter 6.95 of the
California Heald,&Safety Cala Scdin 1,25505.25513 and 25534.1 undersmnd,hat
if the building does not currently have a tenant,that i,is my responsibility 10 notify the
Occupant of the rcyuirementnwhicy/Ymmt M met prior to issuance of a Certificate of
( ncY' A_/&
U/ Signature of Applicant Date
fit' All roof coverings to be Class`•B"or better
uncial- n, Doe
t