00040117 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION; 006 MITNO.
HUILUING ADDRESS: p �1 '(�—'1I1I�/ U� l
77F-. / njTY J , y / py"l Pik/L•'/a/ /'J,J /}/?<' SANITARY NO. APPLICATION SUBMITTAL.
OWNER'SN E: 6/s ) f4l� s/
� NIC CONTROLM
CHD 1- ts ?,SS 6 S a /1 Ytiffi eG C�f� ��yc/ ❑
RCHITECf/ENGINEER BOLDING PERMIT IN W
etez
�JO
U
v�d
t_�i LICENSED CONTRACTOR'S DECLARATION
Oz a I hereby aRmr that 1 un licemed under provision,of Chapter 9(commercing Job Description
l_J with Section 1000)of Division 3o01c Buslness-tm fessiom Code,end my lic,mi.
QymJ in fun forceand eRe, L 6 Ojfl /t_�y
licene CI I3c.x C/r Y. -L
° Date C.ntrmmr A
�3 y
Oa ARCHITECTS DEC N
1 understand my Plans"I be used u public rteoeds
ocE
w'a O Licensed professional
c w OWNER-BUILDER DECLARATION
?>' 1 hereby affirm that 1 aexempt from Nac
e Contractor's Umnsc Law For the -
s G followiam exempt
reason.(Swoon 9031.5.Business and Prolessiom Code:Any city or roomy
w which replicas a pemtit to comWc6 Wer,improve,demolish,or repair any awemre
0.to six issuance,also requires Neapphtian fineuch panus toffee signod3uement Sy. F[. Floor Area / / vtltU:th011
that he is licensed W...at m the provisions of,he Contractors License Law(Chapur9 7V.T �Y+
(minus mill with Section 1000)ofDivision3.oheBpaineasand Profession,Cd.)or APN Number OccupancyT e
Nm m he is ex mpit therefroand the basis patina alleged exemption.Any violation of YP
Section 7031.5 by any applicant for•permit mbj„a the applicant his civil porosity of
pt mom than five hundred dollar,(SM.
1,asownernrthepropertr.nrmr.mpmr,awiNw.geeasthairmle.ompemeuon. Required Inspections
will dothe work,end the structure is ata intended or offered for We(Sm.7W.Business
and Profession,Code:The Contractor's License law docs nor apply to an owner of
Property who builds or improves thereon,sed who does such work himself err drouyM1
his awn employees,provided Net such improvements am not inermed or offered for
as1e.If,however,the building or improvement is sold within one yearaf compldon,thc
owner.Wilder will have the Wright of proving Net he did not Wim or improve for For-
pose of sale.).
O 1.as owner of the property,son..O.'realy me tracdng with Ikensd comnaom to
construes the proem(Se.1044,Business and Prof.ssi.m Code:)M Contractors U.
come law docs net apply N an owner of property who Wilds or improms there Q am and /V f//7/
on
who contracts for such projects with.contracted.)immed ina.11.the Connectors
Liense Law. O
l am.xemp,underSee. .B R P C nor this mason O
0., Dau
WORKER'S COMPENSATION DECLARATION
1 Mrtby affirm under pendty of perjury one of dm following dwlantim:
1have end will for
by •Com fort.of Com.nuo ede.far to erfmo anceof me
tion,as providedJm !or al Section 3100 of the labor Code,fa the pecfomurce of Ne
Z!a which Nis permit"issued.
end will maintain Wnher'a Compensation Imureram.u required by Sam .
Wofthe Idem Code,for the per-fte ncsofthe work for whim this permit is ievud.
My Worker ptpa a ms cc carni and Policy nu
Cartier. `f/ Policy No.:
CE TIFTCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action mdrot becompleud ifdu permit is Intone Waited"I.($IN)
or last.)
I certify Net in the Naftomawe of the work for which thio p.mN is ismed.I shall
not employ any person in any mariner. c .a.uhjwttotheWorkera'Compen-
aid Laws one Ill.a.Dau
APPlicem
NOTICE APPL CANY L aft,mekingcau of Exemption,y.0 should
hemore subjw,m the Workers Component.Provisions of the Labor Coca.you must
I.W.comply with arch provisions or this p.I,shell b<darved revoked.
CONSTRUCTION LENDING AGENCY
Q I hereby atm that Neu its mnsrudon landing agency f„he pertmmmc.of
r the work for which this p,mit is issued(Sm.3091,Civ.C.)
Lenders Name
a > lender',Address '
{] r I certify Nu 1 have read this application and rtes that the above information is
46 o.I.1 afire to comply with JI city and country,diruwes and sure laws relson”to
Z Wilding crommeimi,and bemby amhonre mpecenWivis of this city,.enter upon the
V above-mentioned pmpcny for inspection purposes.
(L F owe)time in save,indemnify and kap harmless the City of Cupertino agehut
V liabilNe,judgments.emu and expenses which may in my way some against mid City
} W in consequence of the graining of this permit.
[ti 6 APPLICANT UNDHNSI'ANDS AND WILL COMPLY WI f11 ALL NON-MINT
� SOU .:RT:GIr ATION.l'.
U Z_
of ApplicancTIRowher Dam yam/ dD
HAZARDOUS MATERIALS DISCLOSURE
Wilt the ePPlicm,or fmue Wilding ocwpmt stone or handle harandousntena Re-roofs
as d.fired by the Cupertino Municipal Cde,Chapter 9.12,ad the Health and Safety
cod..Section 25532(,)1 Type of Roof
0Yea drvo
Will Ne epplicmtor fm`urc Wilding nompr.us.equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hamnims air emominanr m defined by On,Bey Are Air Quality Mamg.mcm installed. If a roof is installed without first obtaining an inspection
°''n'"'
❑Yes No I a ree to remove all new materials for inspection. Applicant
Ihave rt.d the hamodne,material,rtynimmenn rnd,Chapter 695 of the Cali- un erstands and ill comply with all non point source regulations.
forms licalth A Safety Code.Sections 25w5,W33 and 25534.1 understand that if
building doesia cumemly have pan,.th,'n is my msp.nsibiliyni airy the occupant
ofwhich mu ane mus ems of <nifca wy.
�oe Slgnatur Applicant Date
Owner or euNu' g f 25.m
All roof coverings to be Class`B"or better
OFFICE