00040019 (2) CITY OF CUPERTINO - - PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: robuN db l
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ARCHIT HCf//F:NGINEF:R ass- IULDING PERMIT INFO
9�
F dOi LICENSED CONTRACTOR'S DECLARATION
O'0 v=4 I hescby Rffam that I w licem<d ander provisions of draper 9(emm.in, Job Description
wimSection 7n00)ofDiviai SofrW Buaine,sudPa/essienaCode,aM mY lice&eis /` ,f
—C's in full fortt anti air l/_/V1__.a
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DRIT la Cmite
3 0 N Darc Convenor "`r
u O g
ARCHITECTS OECIARATI N ` /✓� j,n
5 I understand my pew am be used u public reads
a i o O Iluaad ProfcuimW
c seas^ OWNER-BUR.DER DECLARATION
C a 1 hereby affirm thn 1 am exempt tram the Coal..',License Law for the
'r C following roan.(S«lion 7031.5,Busimu and Profession,Cods:Any city m couary
R.3 w WWell amounts a Pound,so ceatract.Won.imprnKmm
.deolish, repair my nmember Sq. Ft. Floor Area Valuation
prior to its issuance,also requires this applicant for such Pemtil a rile A sigtr-A automaton
!
JOVA_ v l
that he is Beamed pnaumt to Nmmm
Ne provisions of the Ctob License Law 9 y V
(commencing with Section 7000)ofDivision 3ofmcBusiness and Professions Code)us APN Number Occupancy Type
Wr he is exempt therefrom and than basis for the alleged exemption.Any violsom of
Section 7031.5 by my applicant for a permit subjects live applicant to a civil laundry of I
t rtwr<Jun five hundred dollars ISS00).
wi I, she
war of me poprr.m tar in
wage u We
(Sm.compewtiw. Required Inspections
will domewmk,on,due etrucmristrotintendedm Law
fan (Sec.7 im Business
am Profusions code:Tho eonwnor;License law a&e ata apply to lf aldncr of
In'o
property who builds or improves dierehn,red who does such work himself 1 through
his own employees,provided mm such men-I,menu ere ata intended m oRemd for
ane.If,holder!,the building.,heimpovemenrisaid within nueild or i prove fon.Jr-
eof"leer will have Jr-Wrden.(pressing dial he die ata Wad or improve for pro-
pose of"le.). � 0
71 I,as owvar of the propcny,sm exclusively convecting with licensed contractors to
construct the poject(Sm.RNa,Business and Professions CWc:)The Convector's Li-
&c /
ceLaw due. apply Re an owner of popery wed Wilds or improves datum,sM
wed contours for such projects wish•coatrecto0s)Beamed pumuent a no,Contractors O
License law. s^1
I am excmp undm Sec. .B k P C for oris mason
owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under poulry ofprjury one Of the following dmlaratiwu:
I love end will mainuina Car ifiom of Com sed In r<deimure fmwmk<raComp.-
o nion,as provided for by Section 37d of the Labor Code.fm the performance of On
ork for which diva permit is issued.
]1 have and will maintain Workers Compensation Insurance,OR requioA by Section
700of die IaWr Ceae,fm ted prformsme i f the work for which Nis Pernrl u tuned.
My W. ' comp.aaaen li p upyr-c c 'erPo Policy.: � _ZJ 2T�
Gerrie.: crOrer/J/L��
CERTIFICATE OF EKEMPfION FROM WORKERS'
COMPENSATION INSURANCE
(This secu nneed..be completedAdis permit is forese hundred dales(SIM)
or leas.)
I redify that in the Performance of the wok fmwhich Nis prmil is issued.)shall
rot employ any person in any manner an as to become subjmr to dr-Workers'Compn-
.non laws of California.Date
Applicata
NOTICE TO APPLICANT:If,afar making this Cenificate of Exemption,you should
become subject o the Workers Compnurion provisions of die"nor Code,you mon
forthwith uunPly with such provisions m this Permit mail W datrcd rooked.
CONSTRUCTION LENDING AGENCY
O C) Ihereby affirm that mete is a cormwcdon lending agency for the pMOmwe.of
GGGZ y
the work for which dos prone,is issued(Sm.3097,Civ.C.)
Lenders Name
} lander,Address
1 certify that 1 have rad this application and Rule Jul me above infordow"is
a G coneda.I Agree to comply with JI city said county ordirwuesanalasum laws cluing to
5 z Wildingconapuctitur end hnehyaalani¢rtprceenu ,atesfmis city to env,upon die
U O nWvcmemioned prapry Me inspection puave,
W (We)agree in Rave,indemnify and lump hornless the City of Consoled against
O fF.) liebilmeajudgments,umuand<xprnacs which may in my way accrue Randall said City
} W in consequence of ted granting of this Permit.
nFr L APPLICANTUNDERSTANDS AND W .COMPLYWITHAI.I.NONPOINT
V � SOURCIi RE'UI,
Sipli VConumr Data
FTAL3RDOUS MATERIALS DISCLOSURE
will the applicant&form Wildingnmupenl store m lutdle haoNous material Re-roofs
u defined by the Cupreum Municipal) me,chapter 9.12,and the Hualth and Sarety Type of Roof
Code,Sm to.255320)7 / yP
❑Yes No
Will ted applicant m forum Wilding occupant use equipment or devices whichAML All roofs shall be inspected prior to any roofing material being
cmin haund0as m conumitunu as defined by the Bay Ares AB DOOR,Manegnnan installed. If a roof is Installed without first obtaining an inspection
=11=,7 I a ree to remove all new materials for inspection. Applicant
❑Yes
Ib.Brad the hausdou mmerad,aquimmcru ander Chapter 6,95 of die Cali- un erstands and will,comply with all non point source regulations.
mu Health @ Sdny Code,Sections 25505. 533 sm 2553..I undnsupd that if Jr-
uildingdoes concurrently have amoven,di a my raprous'IiryamiJy Jr-occupant
of usismarets whin sea pew (e Cemfeem of Occupancy
y 4—Cxi Signature of Applicant Date
owner or Writ Dau
All roof coverings to be Class"B"or better
OFFICE