00040069 CITY
OF
GDIVIISIONNO CONTRACTOR INFORMATION: PERMIT No.
PERMIT �Li7'O�'-�o (a
BUILDING ADDRESS: _ - "
SANITARY NO. APPLICATIONSUBMI- LDATF
[��,11 .. VV
NER'S NAME: x,30 E: j�PW 6r- V
NIC ` CONTROLp .
ON, sK - ,�o�Nr �v, Cit 9yoy/ ❑ 9fl Fs-
6 4450 96�. ?.350 HOLDING PERMIT INFO
ARCHITECT/PNGINGLR
c%-nrcS
I t.I ,e66ea7�.Cdo. / J• MGG
s- Z LICENSED CONTRACTOR'S DECLARATION
pz I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
with Section 900(1)of Division Sof the Business and Pm2nions Code.and my It...is
6,j S,c infullfmce wdeRect.
,a ceO dC�raj License Class U, ��
3 LL H Dete Corrector .
g C; ARCHITECTS DECLARATION e
1 undeutand my Plans ahail be tared as Public rcwNx / Q l 1—i C--C
c LicnsedProfessional
OWNER-BUfLDER DECLARATION .
I hereby aff tin that I am exempt from the,Cmuracrofs License Law for the -
Sa a following mason.(Section 7031.5,Bu nmess and ProRssions Cade:Any city or county
w^ which requires a permit m construct.dtm,Improve,demolish,or repair my structure
e3_ prim to its issuuunithm rem the applicant for such parenta file a signed statement Sq.F,t^.F^IOOT Area Valuation
Net he is lacrund pursuant to the provisionsidthe COrsacmta License Law(Chapter 9 W
(mmearm irg with Section 7000)of Division]ofthe Buerieis and ProfessiOm Coder - APN Number OC U ane wry' e
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of / p�• u / P y l J P
Seniors 70315 by any appbcant for i Permit mbje<u dm applicant m e civil penilry of ��OJ OQS J20��6 3 '
nen more Nen five hundred dollars(55001.
❑I,aanwnernrNeprnPeny,rmyemplayeeawiNwagex..Neirame<nmpenaatnn, Required Inspections
willdothe work,end Ne structure is not intended or offered for sale(Sm.7(144,Residents ,
'
..it Professions Cade:The contractor's Limns taw done rant apply to an Owner of
his o ny who builds Pr improves thartnn, pr who nts such work himself or sad for
his own employees;provided that such improvement art not imtendnd w oRcm,she
comm-twile.If,hnwear,thhavbuilding turod m of moan it at the
1 Wild r improve
she
pose,-builder will have the Wrden of proving Net M did not build m improve for Pur-
of sole.).
Ll 1,o t th.P of the Sm.70sa amIia.exclusively convecting with:)TheeCcontmcmrs i- //
consvuct Ne project(Sec.]044,Business rend Rofessions Code:)The Conaacmr's Li-
/Jac),
i-
came law deco not apply je am owner of pmpcmy wlan builds or impmvee Cmarac and �/
who contracts for projau with•contractor(.)licensed purswntm the COntmdW.
D to La
❑
' Ism exempt under Sm, :B hPCfor this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under Penalty of perjury nee of the following chch raticom
I have and will maintain a Certlf tan of Content o self-insure for Worke gCompen. +
satioo,as provided for by Section 3700 of the Labor Code,for the perfomsnce of the
work for which this permit is issued.
' 1 have and will maintain Worker's Compensation Insurance,is required by Section
3 .f the Inbar Code,for 0rc performance of the work for which this permit is issued.
My Worker's Compensation Insurance cemtt and Policy yp ytgq sm,
Carricr:�8M2I1�H USSV0.AuLt Policy No.:z Lg2zCS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(This tection need nM be canparial if ds pemtil ix fofon<hundred dollars(SIM)
in lora)
Icertify that in the performance of the work for which this pont is issued,)shall -
not employ any person in any manner w as in Income subject to the Workers'Computer.
sathm Laws o[Coldi mia.Dote
Applicant
NOTICE TO APPLICANT:If,after making Nie Cenifi<tte of Exemption•you should
become subject to the Worker's Compensation provision of Ne Labor Code,you must -
forthwith comply with ouch provisions or this permit shell be damW revoked. '•
CONSTRUCTION LENDING AGENCY
0 I hereby affirm then there is a construction lending agency for the perfomunro of
the work for which this permit is issued(Ste.7097,Civ.C.)
F.. Lender's Name
(,X reader's Address
k>a ,I certify Nat 1 have read floe application and ore that the above information is-
Cw
z Co.,.l agree to comply with all city and county mdirunces and stale laws nelaning m _
i7 z building construction,and hereby auNmiu representatives of this city to enter upon do
V0 above-mentioned property Tor inspection pmxi, ew.
W F We)agree to save,indemnify and kap henmleas the City of Cupertino town
Ire liabilitie(s,judgment.ensured e.,..which may in any way amme.,mataaid City
je til in consequence of the granting of this permit.
i Oa APPLICANT UNDERSTANDS AND WILL COMPLY WITH AW.NON-POINT p
C.) z SOUR •REGUTATIONS�
w (G
s' n mor Appb<anoG nurser Date
FIAZARD SMAng occuaDISCLOSURE
Will the applicant orfumre building occupant store or laMlehazardoue ma em, Re-roofs
as defined by the Cupertino Municipal Cede.Chapter 9.12,and the Healthand Safety
Code,Section 2553200+ Type of Roof
❑Yea <No
Will the applicant Or fumrc building occupantpse equipment or devices which All roofs shall be inspected prior to any roofing. material being
emit bamrdous it comuminecs in.defined by$a Bay Arca Air Quality Man,panumt installed. If a roof is Installed without first obtaining an inspection
District] I agree to remove all new materials for inspection. Applicant
❑Yes IFNI,,
I have reed the haurdous marc2irc
terial, a made,Chapter 6,95 of Ne Cell. understands and will comply with all non point source regulations.
g
forrl0 g u d Safety Cade,Secdom 25505.25577 and 25534.I undersand Net if the -
bui111 6 nm curtemly haves 1 1.that it is my responsibility to notify Ne occupant
Of the 1..,,whin yye ores prix to issuance of a Certificate Fob penny..
10/00 Signature of Applicant Date
Owner Or authors •gem Date
All roof coverings to be Class"B"or better
OFFICE