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00050123 CITY OF.CUPERTINO - PERMIT NO. e B' amLDING DIVISION PERMIT CONTRACTOR INFORMATION: p�-113 01IDy / I /flm/A✓' �• I ('�Y I�',I 1•�� 1� SANITARY��� O/LICATO)NSSUUB rTTTALDATE OWNE4 �CI�A X1�•i/I D(iI1 W VVI't�1/��'--) ��/t� 1 �j/.}�//� 5 1 O C I" l �i II g It4V` l ar t s N/C CONTROL# NiHoNnel RCHITECT/ENGINEER ✓'• BULGING PERMIT INFO muJ vk-iGc - r LICENSED CONTRACT'OR'S DECLARATION - 1 hereby affirm mat l am licensed undo provisions of Chaprcr 9(commencing Job Description <IrF_ to Billfmci]000)of DivixionJ ofine Busitrcas and Pmfwioras�aW mylicense is /�JJ 1 (� to force =R t _ -/ Ls•.\/l I�r v ��a. y re y License Cla Llc.g L 5,.'r Date Conuacm F'_C a ARCHITECTS DECLARATION -r I connectional my plans shall he used as public records z 6 in Pc licensed RoBssiaW OWNER-BUILDER DECLARATION t?a I hereby of rte that I am exempt from the Contractors License Law For the _ s he following i.(Section 703 IS.Business aur Profmiotu Cods:Any city or cormly ' which re,xii.a pmnf m cmmuum,arer,improve,demolish,W repair any structure a Sq. Ft. Floor Area prior its issuance,also¢quires the applicant for such pmun9 file a signed chapt em (-f Romethea hear lung with pursuant come of Division 3 me is Buecmrs license law sCode)r (commencing wim Section 7")of DivisionJofine Business and Pofessiom Code)or that he is exempt maefrom and the basis for the alleged exemption.Any violation of A PN umber Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 © 2 F1t moor mut five hundred dollars(5300). 1,as owns of the Persian,or my employees with wages as their sale cmmpnsatien. Required Inspections will do the work,afdme avucturc is not intended moRered fonac(Sec.7044,Bus and Prolesamns Code:The Conuactur's License law doea Ins apply to an mvive of ' property who W iMs or Impreva thereon,and who does such work himself a through his own employees,provided mat such improvements are era intended or offered for , /• "+ . mate-Wildevcr,t]l Wilda,bur impmvemrm viscid w id rent Wild or i completion,improve the . . r-W ile) will have me When of proving Net M did not build m imptmve for Pur- •` a pose of sowne:. '7 77 3 2 2- ❑L u owner of me property,em exclusively cofessiong with:)'F rad mmoerms i. constrvct me projat(gee.]IN4,Business and Ro%e Wi Code:)Thr Con a,Li` ase law does Int apply a is owner of pvpmy who Wilds m improves thereon,and who nLew.fo such piojects wim a conuacoorfH licensed Wrsuant m the Conuacmrs 0 License slaw.' - ❑TemexemptuoderSce. .BBPCfa this reason `v/ a� Owner Data _ �,•v[/ WORKER'S COMPENSATION DECLARATION V Q 1 hereby affirm ceder paWty of perjury one of Oe,fallowing derWatias: 1r1 ow and will maintain aCenifinte oco arm to self-Insure fo Wodrers Compen. lJ tion.m provided fm by Section 3700 of me Labor Code,for the performance of the work for which mix permit is issued. ❑1 have and wi rfa tin Wmh Compensation Imurmwe,as requital by Section 3]00 of die 4W �i {{p emf me woh for wli�cl�Nyyp�y MY Worker's p sill I earner and Polis ti v'If" /if/I I Jt 1 / Grniee Policy No.: lL s e CERTDTCATle OF EXEMPTION MOM WORKERS' ' COMPENSATION INSURANCE (This a.esd trot be completed ifthr permit is fern ehtedred ddlsr(5100) - orins.) - I certify that in the pertorriameof the wok for which this permit is issued,l shall not employ any preop in any manner an as an Wmene.<ub m,,.the Wofken'Compn- .am laws of California.Date Applicant - NOTICE TO APPLICANT:IL after making this Conflate of Exemption.You shouts - become subject m me W9heea Compnsauon provisions of The labor Code,you must ' f ndiwith comply-wim such provisions or Nis pnnit shall he deemed mokW. CONSTRUCTION LENDING AGENCY - 0 Ihereby afromere is a ounwar lending agency for the perfmmamce of r Z ythe wok for which this permit is issued(Sec.3(97.Civ.C.) , Lender's Name 7 Iamlaex Address W A1 cenify that 1 have mad oris application and soon that the above iNomutien is ' Pct correct.1 agree to comply with all city and mum,oedinanres and ams laws relating m Z building construction,and hereby authorise repcasmatives of this city to enter upon me - - V C aWvememioMd properly,ter inspcuoe purposes. W Fw (Wr)agree to save,indemnify and kelp hmmlrss the City of Cupertino against - 0 f•) Iiebilitiex,jWgrre,nts,coutsand rxpnica whichtmy in any way seethe against said City ` �., k7 in consequence of the grartung of this pmdt. ' F 0- APPLICANT UNDERSTANDS AND WILL COMPLY WITH At.].NON-POINT C.) ` SOURCE REG ULATIONS. Sigmamre ofAppIir.o%7mumcwR Date T-7� ` HAZARDOUS MATERIALS DISCLOSURE " Will the applicant or future Wading mcupsm stere or haWle hanrEoas materia Re-roofs az defined by the Cupertino Municipal Code,Chapter 9.12,and me Heath nd Safety - Code,Section n532(a)7 Type of Roof ❑Yes ' ❑No Willthe applicant or future Wilding occupant use e,iipte,nr or devices which All roofs shall be inspected prior to any roofing material being emit hazardous air contaminants as defined by the Bay Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection Oyes ON. g I a ree to remove all new materials for inspection. Applicant ra.enadth h. ars mari .re9nirem adrChapte;b93rfthe Cal, understands and will comply;with all non point source regulations. I"Health&safety Code.Sections 25505,25533 and 25534.L understand thst if me - - Wilding docs era currently have a ennmL mar it is my rrspomibility tu notify the mvpent of me reyu msents which mud be met prior to issuance of a Certificate of Occupancy Signature of Applicant Date Owner or autlwrized age¢ Date .. All roof coverings to be Class'B"or better OFFICE `