00030138 (2) CITY OF CUPERTINO PERMIT NO.
. IIUH.DING DIVISION PERMIT CONTRACTOR)TRACTOR INFORMATION: 000-5 ,0 3
BUIL DING AUDRCS��� i'; t ///I./"A� �u� Only, le
.r' WU/L y/ SANITARY NO. APPLIIO(J SUBMCUAL DAT
NAME: /'
V� #YX N/C CONTTRROOOL•#G
40 �ra�yC�l/111uawey, V1959�s °
ARCHITE(TOENGINEER .HULDING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
p = I hereby aRrm that I un licensee under pma;uana of ampler 9(commencing Job Description
F_Cm with Section]000)ot Division lutes,Business and Prosampos Code.and my liwnu is -
-Kd6 in full Force aril ellen '.2 A
060 Liana Class L
j.2 LL F Dele GOnIRLmr W �///�/
u O ARCHDECI S DEC occurs,I undentW my piens slWl be trail u publicblic records
w 0 O Licensed Professional
c u OWNER-BUR.DER DECLARATION
f-¢_ 1 hereby affirm that 1 an exempt from the Contractors License law for the
d m following reason.(Section'1031.5.Box.,and Profwiom Cade:Any city ca wanly
w 3_ which mauves a permit w construct. improve.&=Jim,w repair any strammec. Sq. Ft. Floor Area �laluall�oppp
w
per., isstrance,also routines the.p,hem,for such pemul W file a aignd.tetcment p�, d�
lost he is licensed pursuant Ne provisions of du,Contractors License law(Chapter 9 /1 U
(commencing with Section 7")of Division 3 of the Dismaae and Professiom Cods)or n
ppN Number Occupancy losd thlitr
t he is exempt therefrom ae es far the.Il,grd exemption.Any violation a � �% P Y T YPe
Sedco 701.5 by any applicant For a pmdt subjects the applicant to a civil penalty of
w more Nen five hundred do Rus(5500).
I'..aawu
norNeProperty.armyamplayaeawith w.gca.,thei'miemin'tar on, Required Inspections
will do the work,ad Ne mppmre is but imex dd or oRaed for sale Sm.7()44.Business
and Profession"Cale:'ns,Cmvactor's Liam,law does fort apply to an.,of
property-W Wile.or impmvn themed,W who don such work himself w through
his own employees,provided that such improvements see nor intended or offered for
sale.If,however,the Wilding or improvement is sold within one year of completion,the
her-h ildrr will have the Wrd,n of proving that he did not build or improve for par,
pox of aaleJ.
D 1,as owwr of the propny un exclusively contracting with licensed.. . .in
construct the project(Sm.7W.Business W Rafcuiom Code:)The Contractor's Li-
cense law does tort apply ro an owner of property wW Wilds or improvm dommi.end
who contracts for such pmjmu with a contractor(s)licensed punment to the Cuntracmrs
License law.
D I am cxcmp under Sec. .B&P C for Nis reawn "
Owner Dau /
WORKER'S COMPENSATION DECLARATION
1 handy affirm under penalty of ofCone of Ne following daluati Ci pm V
1 have and will maintain a Certificateonrv m u
¢of Consel6imurt for Workcr'c Comw
on,"pin dadfor by Sation 3]00 of the Labor Cd<,for los pAwmaac of Ne v
k for which this pmdt is issued.
1 have end will Woman Wotkcr,Compnsadis.Imureme,ss requited by Section
3700ofthe UWr Code,for the prrfomonce of Ne work for whichQ this mnit is issued.
My Workers Co�npc setio9,Iq� s �eme,and Policy nuyS/�j.
Carrier: �zT/A7C T'ou Policy {/-
CERTIFICATE OF FXWMON FROM WORKERS'
COMPENSATION INSURANCE
('Dais sw[inn nandnot becwnpleted ifthe phren is faweM1wNeddollu.(5100)
w Ica.)
1 emify Net in he prfminimmaf the work for which this mmol is issue,l shall
not employ any prison in any mentor w as to become<ubjecna the Workers Compen-
sation Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
Wcome wbjen to the Worker's Compnvrion provision,of the Labor Code,you man
forthwith comply with such provisions or this permit shall be dammed revoker.
CONSTRUCTION LENDING AGENCY
Q OIhcrtbY dfinm that dameis.wmWcti,a leading agency for dee performene,of
r the work for which or,
permit is issued Seat.ID 'Civ.C.)
a Lenders Name _
Under,Adrt„
fz7 I certify dor 1 have rad this application and state that the above information is
G. what.I st,a m comely with all city and comity ordimwn and sure,leas obtain'..
Z WildinQcmauction.and Wrehymahodm rtpresentmiva of dimly to enter upon the
U O move.mmtioncd property for inspection purposes.
W (~ (Wc).gree to save,indemnify and kap harmless the City of Cupnina against
U liabilities.judgments.corn sed expnaes which may in any way acerae against said City
y W in emuquena of Ne granting of this permit.
E+ A- APPLICANT UNDERSTANDS AND WILLCOMPLY WITH ALL NON-POINT
V z SOURCI?RI:GUI.r]jL(1Nti. w � I/� O
(tea-rte— r / /
Sigmturetil p 1w.9C.tractor are
RDOUS MATERIAIS DISCLOSURE
Will dse applicant or future Wilding occupant arm,at handle hazaMous mmerial Re-roofs
u defind by he Cupnlno Munic{pl Cade,Chapter 9.12.sed the Health and Safety Type of Roof
Core,Section 2553x(,)] / YP
Dyes ®'N
Will the,applicant orfuture Wilding aaapantuse eVipmentordevismswhich All roofs shall be inspected prior to any roofing material being
mit bauNoua au cmumimnuas dermal by use B.y Aroa An Quail Mmagcmcnt installed. If a roof is Installed without first obtaining an inspection
" °'] P4. I a vee to remove all new materials for inspection. Applicant
40 ❑Yes
l have mad the hezandwamateriW requirements oder Chapter 6.95 of lir Calm understands and will comply with all non point source regulations.
folia gather&Safetycame Code.Satiate,that i.2553]esp 253]x.l undrsaurth that if the --f, /,
ofihereducerut. currently love beintsRint it ismunce ofmibilityotwti(Y de oaupant V�_ /i��T
of the rtyuirtrwntswNch must W Ortel pier w isamrce of a Cmrfceupf o,�p�
_ CC..lXI�.� V //U Signature o Applicant Date
Owner ser euN 'zed elle au
All roof coverings to be Class"B"or better
OFFICE