00030070 (2) F
OF CUPERTINO PERMITNO.
ILDING DIVISION PERMIT CONTRACTOR INFORMATION: O0 030O -7O
AUDIT&SS: SANITARY NO. APPLICA'p%NSUWFTTAI.DAT
�o TA�STAJ f9 V� ,r' ��� so//0NAME: s
NIC CONTROLp
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ARCHITECT/ENGINEER BALDING PERMIT INFO '
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fe�'6' LICENSED CONTRACTOR'S DECLARATION
zoy IhucbyaRrmdateltenlicenxd.altoprevisionsofChapter 9(com -1-& Job Description
°_F 'Nilfoom rad'IfeflNviahn3nrlbeanaine,..ndemre.,inroenae.wmrlittveis � (,—S'C'02.Y (—1 OU
a x Nil force W eRect.
oc O Littnx class Lic.N
Date Contractor —*�`_•"—'k'<<—'—"'a^` ��
a pg ARCHITECTS DECLARATION-tet
N 1 understand my plans sIW I be mud u public remands
ce
w E:°C Licensed Profeuional
c u= OWNER-BUR.DER DECIARATION
C'<rI hereby sDirm that I on exempt from the Contrtcou's License Law for the
5�G following relmun.(Soc,um 7031.5.Business and ProAssrut u Come:Any city or enemy
c.'t whim regaines.permit In c.'.alter,imgm e.dermbah,or m*'any suumurc Sq. Ft. Floor Area Valuation
prim to its iuuamtt,also rtgon.the applicant for each permit to file a sigrcd aratemem ZOO Y
slut ate is littmd purauanttodu previsions ofthe Contrvaote License law(CNqu9 �Q -� 13 4�(' �_ T�
(commencing with Section 7000)of Division 3ofthe Betimes avd Profeuiom Cde)m APN Number occupancy Type
that he is ceempt therefrom std the basis for Ne alkgW csialmon.Any violation of p Y Yp
Section 70313 by any applicant fee a Flood subjects the applicant to is civil pnwhy of
pono mthan five hundred dollen($500).
I.aenwnerarthnpropenr.armremptaytt•withw.gesstheirxlecompenxdnn. Required Inspections
will Fr the work,Coulee structure is not intended aoserd for salapply to All ownBuser of
_ and property
whom Cade:iThemp Contractor's icenx law does rad aptly to lf owner of
r - property who buildi or improves t such i,and who macs ouch.work himself or or through
edfor
his own employers,gnvidd Nat such improvements arc not intedd or offered for
t rain if.hcswcscrwill h v Wilding or impmvemeng t sold within act old or improve for the /
orean We.).will have the When of proving that the did not Wild or improve for pun 6
gran of xloe.).
o(the property,am eadmivdy connecting with licensed canvanas to `O /
cons n t Ne q.jm,(See.7060,Bull...anal Profeuions Cdc:)The Con.&.V-
cenx law does not apply to an owner of property who Wild.or improve tMton,and
who conuacu ler much projau with.cmnuactwo 1'.."put.to the cane sctoft
Littnx eco.
exempt un rSee .B&PCfor this n:uon
�' Ow Deu���—OO
N RKER. COMPENSATION DECLARATION
I hereby.IErtn Ity of pe jury mute of the fallowing dal.ntioru:
(have ed will mainuina Cenibcate or Conxm. rb6fn mfa WokdaCompery
saline,as provided for Section 3]00 of Ne Labor Cada,fa the perfomunce of the
ink for which this permit is issued.
7 I Tuve and will mainulr Werke/s Compensation Insurailook
for who ss his per by Section
My ortee sLaborCoto came,ren the pcdorma me of d wok for which this permit is issued.
Ca Worker'.Compns,ation Insurance curie and Policy number are:
Cama: Policy No:
CERTIFICATE OF E 10N FR WORKERS' '
COMPS AnONNINSURANCE
(Trice seldom reed trot be completed pladifthe permit in roroabuMed tlollan(3100) '
Wesel
I certify Our in the performance ofthe weak for which this permit is iuud,I shall
not employ any pinion in any manner mu as to become subject o the Workers'Compcn-
utilm Tawe of California.Dare
Applicant
NOTICE TO APPLICANT:If,after making this Cenificare of Exemption,you should
buomc subject to the Wmkefs Compensation previsions of the Labor Cade,you must
forthwith comply with such provisions or this Noun shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
0I hereby dRmr that there is a cormmction lending agency for the performance of
Z Ne wak for which this pemul is issued(Sec.3097.Ci,C.)
Ledels Name
dr 7 lal6m.Address
{� I certify Thu 1 have read this application and sure that the above infomution is
a 0 Co.,.I agree to comply with all city anal county onsirunce read sure laws miming to
iD Z Wildirrtcon.muctimn,end herebysutho met nepxxmativea of Nis city to eolitionthe
V C aboswi.mu and property for inspection purpmxs.
W P (We)agree to nave.indemnify and keep hanmlea+the City of Cupertino against
r) liabilities,judgment,more a oil sFenxs which may in avy way xcmeag-lost said City
W in consequence of the granting of this permit.
�+ APPI.ICAN'I'UNDERS'rANIts AN 11 WII.I.COMPLY WI1'It ALL NON-POINT
'Ii REGUTATI S.
U .Z.
'igtuure of Applicaunco to Dau
HAZARDOUS ERIAIS DISCLOSURE
Will dcapphrant crft.Wading acipsmtstomm hatde hasookos m.tcual Re-roofs
u defimd by the Cupertino Municipal Code.Chapter 9.12,and the Health out Safety Type of Roof
Cade,Section 25532N)+ Yp
(]Yes IKO
Will the applicant or future Woccupant use occupause equipment or devices which All roofs shall be inspected prior to an roofing material being
mit haaandaus ae mrtarrinanu as defied by the Bay Area Air Quality Management installed. If a roof is Installed without first obtaining an inspection
11.1c'? I aree to remove all new materials for inspection. Applicant
❑Yes yin
Ilive remldie .,matati.laremiimmenreunder Chapter 6,95oftWCali. understands and will comply with all non point source regulations.
omia Helth&Safety code.Sectors,255115,25533 and 25530.1 andnaund that if the
Wading date oat com ntly have a tenor,thas it is my supomarlity to reify the occupant
rtquvemenm which mod W me prim to issuance of A Cenrficane of Occupanxy.
Signature of Applicant Date
r ar au Dan
All roof coverings to be Class"B"or better
OFFICE