00020167 (2) CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 00172 p) I
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NIC CONTROL#
s- Hayward, 2 ❑
ARCHITI;CT/ENGINLER 571d �y � ,y�j
BUILDING PERMIT'INFO ,-,
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LIC ENSEDCONTRACnder P DECLARATION
of CON
o°=0 1 hmcby aRrm Nn 1 am licensed under provisions of Chapter 9(comms mg Job Description
�_E; with Section)000)ofDi/vj}'oon3of dm Businase rend Pofesaiom Ca/Q/c my li
xf,o mfull forceand eRcn.f / L ('�er //(.N��j/ //G�/���/%% "��N/ /oe/ s'/�✓
—y eco i Uan a Cleo Lic.#
Dore Contncmr
t¢_.O g ARCHRECT'S DECLARATION
f v�1— 1 undcmard my plan anall W used u public recoads
�i¢p
u. ° Licensed Professional
OWNER-BUILDER DECLARATION
E Z< 1 hereby al(nm that 1 am exempt form the Coneraceres License Law for the
O following reason.(Section 701 L5,Business and Professions Cods:Any City w county
which mqubor a permit w content.Blu1 improve,hmohah,or repair any xtmcmre Sq. Ft. Floor Area Valuaticy
prior to&ixsuawe.also requires the applicwtforxuch permitmElcaaigbed aunmrnt //f� �j a(/
Nat rte is licemed purauam to Ne provisions oftheCrntracsore Licrnse Lew(Chapa9 G O•
(cam he
exa pa Secdoofland the
basisonl th al Businexempton,Anyoumonof PN Number Occupancy Type
Wt he is Camp Npdrom end or aura for the subjects
the exemption,W Any vluhdon of ,.a P Y YP
Section Non n anydreddmtforapermit mbjecu Ne applicantmacivil pezWry or (•/A 2—.not mart Nen Eve hundred dollars(53001.
wi I.otins, Mocpropeny.mmy cmployeeswimwages for
c0mpenaulon, Required Inspections
will htM work.aaddrcarrucmrt is nor innodndwoRaed fa adelSec.7044,Buribeu
and Profusions Cade:The Contractor's Liaise law does nos appy m an wrcr M
property who buil&or improves Merton,and who dao such wort himself or through
his own cmployaa,p n,ided that such Ramon.art.1 intended on offend for
We.IL howear,that buil&ng err impovemrnt is wld within om yurufcwnpledm,doe
owne,imider will baa tad Linden of proving that he did not build or improve for pen.
pew of sale.).
1,u aorto of the property.am exdvaively contracting with licensed m...to
consumer me project(ser.7W4,Badu sed Professions Cade:)The C.rummors U.
conn law does not pply to an owner of property who bunds or improves merman.and
who contracts for such projects with a eontracmr(i)licensed purauent ro me Contractors \�
License law. -VQ
D 1 am exempt under Sne. .B k P C for this won
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of
teperjury one arms,following hCluY.c. O
1 have prod will nee b in a d.37M of the Commit'.Cosa,in, far er—Compoe Q
melon,a phichhd feebySadon 3)00 of the labor Cade,/or Ne penomtsnrne of❑m
w which oris permit is issued.
oro 1 have end will maintain Wnrtds Compensation
rpby Section
3)OOofthe laborCode,for Ns performance ofNe workfor which this permit is issued.
-
My WroteC moeoaa�ti�.Ili yner sod Policy n /
Curler: K/ /VEYj<t—Policy FROM
CERTIFICATE OF EXEMPTION fROM W00.1(ERS'
COMPENSATION INSURANCE
(This section mud not hecompletedifine permit isforces,hundaeddMlato DlOo)
or less.)
1 teary,unit in use,performance of me work for whichthis permit is issued.)mall
act employ any piton in any member w as to become subject to the warren'Compen-
moon Laws of CaliNmis.Dell
Applicant
NOTICE TO APPLICANT:If,after making Nis Cenifican of ExemWoo.You should
become subject In the Worlds Compensation provision.M the labor Code,you must
forthwith comply with such provisions or this Permit shall In dermad newked.
CONSTRUCTION LENDING AGENCY
QI botchy affirm Net mere is a constmedon lending agency fort he perfum+ana of
ry me work for which Nis Amin is ixsund(Sec.1097.Civ.C.)
Leaders Name
a > Leaders Addreu
r� 1 certify that i have read this eppleuion and sure that the shove mfomtsdon is
Fr correct.l agree to comply with ell city and county ordinances and state laws mlving to
=1 Z Wildingconstrucdms and hereby autlsrize repeeaenuriva of Nis City in auerupn the
U above-mentioned popmy in inspection purposes.
Ga F (We)agree In one.indemnify and kap harmless he City of Cupertino ageimt
U hobilitiu,judgments.costs and Captions which may in any way acme against and City
n conuqusace of 4rAl
6 of Nis peardt.
F� rAPPLICANT UNUSAND .'OMP1.Y WITHALLNON-N)INT
Z SOURCEREGUTAA
o0
Sign.mrtaf Appilm tet Date
5 MATERIALS DISCLOSURE
Will thaepplicant or fumrt building acupant a N-rehandle harardon,material Re-roofs
u defirsd ay the Cupertino Munim I Code,Chapter 9.12,and the NdN and Safay Type of Root
Cods,Section 255]2(.)? yP
Ycs
Will the applicant or fumm Wilding occupant use equipment err dedas which All roofs shall be inspected prior to any roofing material being
coal Innuendo.,air Conumivnu u defined by the Bay Area Ab Quality Management installed. If a roof is Installed without first obtaining an inspection
Di'"" cl,// I a
Yea ree to remove all new materials for inspection. Applicant
a
Ina read the huemom mmmrod;mq.immens miner Chapter 693 M the Cali- undg
erstands and soil com with all non point source regulations.
None Nsalth A Safety Coal Sections 25505.25511 and 25534.1 understand that it do // a{D
Wilding does nor currently have a tenum, "s my respunsibiliry to notify me occupant ll✓ (l
of Ne rtyuberrcnts coni the nn. seance of a C�ne M(%up.ncy�
v Signature of Applicant Date
Owner err euthodznd age one
All roof coverings to be Class"Bfe or better
OFFICE