00020058 CITY OF CUPERTINO, PERMIT NO.
BUILDING DIVISION - PERMIT CONTRACTOR INFORMATION: O Q Z QS
BUILD INGADDRF.SS:
,Z OS!s ,Clrirefta On ' wATQ� N041'EkS �o�7A Lyt(�.,�JW. SANITARY NO. APPLICATION SUBMITTAL DATE
OW ER'S NAME: 970 E• Main si/' //L(/Cl
NIC CO.NTROLN
P atea) T2s-Ss�92 C�rGss i1?09y, 64.9s9els ❑ f
ARCHITEC(ENGINEER /—ADO -S33- S72 IULDING PERMIT INFO
QUt!
yzm
s-? LICENSED CONTRACTOR'S DECLARATION '
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
F¢En,hw ani S.d..7M)aDivision3of6c Businesand Profemiow Cade.aM mylicenmis
sczG License ClasMeR .� Lic.N ;314573 `VVU/V� ' I(4',`!/ L�. '•-/_ �V'✓�/W' / r
ou O U Dem Conuacmr,
uy C ARCHITECTS DECLARATION '
1 understand my plans shall be used as public records
i=E9. Licensed Professional
uKi=y OWNER-BUILDER DECLARATION
1 hereby affirm Nn 1 am exempt from the Contractors Licewe Law for the
E S following reason(Session construct,1031.5,Business end Profssiow Curie:Any city err county
ms
ueci which reclaia permit m construct,alter,improve.demu an
demolish,or mpy suumme,
`3— Ptiwto its issance,also regair,diaappBwm forawh permit m Elea signidsutcnxnr Sq. Ft. Floor Area Valuation
that he is licensed Pursuant o The provisions of the Cwoocmes License Law(Chapter 9 - 700- 00
(commonsing with Section 7")of Division 3 alms,Business and!Professions Code)car ne Occum
APN Number a
Nat he is..Wt therefrom and the hasis for me alleges axempiom.Any violas.of Y Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Emery of
1 mare then five hundred dollars(S5W).
m bar P
pI.as owner of the property,or my employees with wages w deir sale wmpneation, - Required Inspections.
will do the work.end 0e,strucmre is urn intruded or offered for We(Sec.7014.Business -
and ProCo
fesomeas de:The Contractor's L.ieme,law does nd apply to an owner a
property who builds or improve thereon,and who does such work himself or though
his own employees,provided that such impmvcments erre not inmtded m oRrmed for 1
We.If,however,the,Wilding or imptwsm ss,u sold within ane ywof Warnesion,the
r-Wilder will have the burden of proving Net be did not Wild or improve for par-
panic of We.)
❑1,u ewrcr of the proper.am eacwsivrly conbacung with licensed contractors to
c.La she s;not (Smapply
roan,Business and Professions Code:)The Conpµtor's ad who
claw docs not apply m ts owner of mpropny who Wins rs impnvs Carton,end .
Lima.Lactsfor such prolmu with aconwcmr(s)lkeneW personal m the Canvecmfs
License Lew. -
❑lam<aempunderSa. .B&PCfor Utis rtamn
Owner Dole
WORKER'S COMPENSATION DECLARATION
I hereby.lfirm under parlay of arryry one of the following declasm eat
-. ❑I have and will mdouin a Cmificane ofeonsenue self-mom,for WorkersCompo-
tiou.as provided for by Section 3700 of to Labor Code,for the poformanee of to
Vr which this permit is issued.
Q�1�hfaove and will maintain Workers Compensation bourn e,ae regnired by Section
kfodse la W,code,far de,pefwrwtcaofthe work for which this .it is issued. ,
�MMyyy warrker's Coag¢ear ty���rulc5,urior and Policy n /9,^ -
Grria: MAA I G A3IM Policy No.: n�ll� .•
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sarin need not becompleted Buse permit is foronehundreddamon,$XXB '
or k.,)
Irectify that in Ne raf...ofthe work f.rwhichthis permit is issued,l shall
•
not employ any person in any manner m as an became,subject to the Wortrn'Compen-
mtion Laws of C,Rfami..Date -
Applicant,
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should t
become subject to the Worka's Compensation provisions of the Labor Code,you must
fotOtwith comply wit such provisions or this permit alull be do med revoked. _
CONSTRUCTION LENDING AGENCY -
O 0 1 hereby affirm that there is a cunoWction lending egcwy for the performance of `
Z the work for which this permit is issued(Sm.3037.Civ,C.)
Eon Leader's Name -
yr > Londia,Address
W aI certify that I have read this application and stare that the above infomatiw is -
D z coned.lµren to comply wish all city and county on itunces and state laws relating to -
Wilding conmuca...and hereby•mheriu represenwives of tWz say m enmm upon me
U O .ays.mmunnw pepmy for mepecuen puryoses.
W E. (We)agree m save,indemnify and kap humiss me City of Cupertino against '
O r, liabilities,Judgments.costs and expenses which may in any way amour agiiml said City
>a [roe in mmequense of m,granum,of Nis pemut.
F APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT `
U Z SOURCE REGULATIONS.
Signature of ApplicanuContnnor Due • -
H RDOUS MATERIALS DISCLOSURE
W;n the appliezm or future Wilding reeapant store or handle hauNeus-social Re-roofs
w defined by the Cupnim Municipal Code.Chapter 9.12,and the Health and Sdcy, _
Care,Section 25532m)? Type of Roof
Yes
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing, material being
mailhauNous ah mnumiwnLL as de faced by me Bay Area Au Quality Msm sbaml installed. If a d roof is installed without first obtaining an inspection
Disarm?
ver �4•Y^A/ I airee to remove all new materials for inspection. Applicant
❑
- W e resdi the namdpmaterials n maker Chiral,6,95 of the Cid, understands and will comply with all non point source regulations.
forma Hirai&'Side,Code,Sections 25505,25533 and 25534.1 understood that if do , q/_� /X/
building does owl currently have a amen,Nu it is my ma,omibility mar
early the mmpant /i rev
of the reyukemenu which must to met prior m issuance of a C<nilifn a rf Oce pen
owner em.ammiznd.gent ��Z �J Signature of Applicant Date
All roof coverings to be Class"B"or better
OFFICE