08100164 CITY OF CUPERTINO
BUILDING DIVISION PLIT�AHT xt.-#o0Y',N�:,•]v4f�UC#T.x�.aQxt."� 'N4�.>®F_.I�D
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BUILDING ADDRESS: PERMIT NO.
10181 EMPIRE TBD - To BE nPTRRMjNRn npionlf;tl
OWNER'S NAME: PERMIT ISSUE DATE
p SA CONTROLNO.
ARCHMCTIENGINEER: BUILDING PERMIT INFO
f BTHRM RMDL(60SQ) ;NON- BLDG ELECT PLUMB MEcx
O O O 0
no, LICENSED CONTRACTOR'S DECLARATION STRUCTRL iI3 .Job Descrnon
I bctcby affirm that lw limned under pmvitimuof Chapter 9(camme mg -_^T^ -^.--M1^— —_-.^--.^
¢ wideSmtian7 rxi Hsi ofthell. evand Profession Code.arW myliccnm is
in full Tome and of ,
�'A Llcenm CI Q LK.t
o Dau: 7rSDcmr
epp7W7W ARCHITECTS DECLAc occur
y s' 1 uMersunJ my plane shall ha uad u public rtrnr s
JyU
o LiccnaJ Profcuionel
Oat I am exempt
from
DECLARATION
COO1 num .D ect Sol 1 1. exempt from O r Contravenes L enc Law for the
COO following emits 1031.5,Business and Pmfcatiuv Code:Any city or rounry
which jux a permit re conurun.alcor,improve.h permit t ears asir ed omens
give PHarmitsissnavc,alm rtquim mprovisions of for such permit mice a,Law(Chapter
slacmcm
a maAeoncin, eitPuntion10th)ofDaflkhee ort.alJcenmss (C ode)., Sq.Ft.Floor Area ' Valuation
y�3 thammendne pt Semon t and of lausis n3 of ft al Bu d coomp on.PooAny
Ction of
y��
that he ls exempt thertfmm and Vc basis for the alleged esemPtion Any Holation or
Section 7031.5 by any applicant for a Puma mbjectt me applicant m a Civil pcttsRY of APN Number Occupancy Type
not mart thm five hundred dally s(1500).
❑1.u ave of the pmputY•a my wployw month wgn u they role mnpetuation,
wad dothework,ande,The ComurotS Uramn Law dedfu notapplytUM,Buri Of
and Pmresdav cane:The Conuacmf,tar......law don not apple u an owner of Required Inspections
Pro .pW,mbuipldsorimgNavtsacd i.pg vem.0 damac„nout cinundedamovBJerrra�r Wftvhewcop{wkhnIf.
uL
howeves,the buildmilorimannlsmid withinoro Year ormmfbuiWu wiBhave me burdam of proving that ha did not build or improve for
_
0.
purpose of
cola.).
❑1,an Owner of the property,am exclusively contracting with licensed Con namax m
Construct the prejem(Sec.7006.Business and Profesvov Code:)M Contrame's U.
Conte Law docs not apply to an Manor of propenY who build,or improve thereon.and.
who contracts for such pmjem wide a eanuanor(s)liceved purment an the ConuacuM1
License law.
❑I am exempt under See .B&PC for this nomn
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hareby affirm under Penalty of perjury one of the following deelmtiov:
❑1 have and will maintain•CertiOnuof Covent an mlyivum forWorlmesCoMpann-
sedm.u provided for by Section 3700 of dee Lmm Code,for me performance of the
work for which this permit u issued.
❑1 have and will mainuin W~.Compensation Ivuconce,a required by Section
3700 of the labar Cod:,for Ne perfmmarws of the work forwhicle this permit is Wood,
My Workd,Com�ap.e�va;tian �nay�m�or and Poll
Carie: ST'/17 Ll wfl/+'!"' Policy No
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mda modern reed Out In mmpmted Usha permit is forone hundred do0as(SIaD)
v kass)
I cmifv dist in the perfomace of tae work fm which this Permit is issued.I shall rot
employ any Foran in any m nnorm as to become subject to the Worlmor Compevation
Laws of Califomic Dau
Applicant
NOTICE TO APPLICANT:If,after making this Cenifiau:of Exemption.You should
become subject to the Worker's Compensation provisions of the labor Code.you muss
Oforthwith comply with such providov Or Nu Permit shall be dComcd rtakcd.
CONSTRUCTION LENDING AGENCY
1harw aRm thatmere isS turned
len ding egcncy fear the perfwmenecof
the wart for which this permit R issued(See.309T,Civ.C.)
GQ Lcndim.Name ,
�,� l.cndeh Addreex
cence mat 1 pate end this application and,tau mat and
Shote informative to
5 cortin 1 acme m comply with all city and county oNinaoaex and suis law relating o
.Q lbercngcationed pro and hereby amonmrtpeetenutives of suis city mmteruptn lha
r L31 aeove-mendable propane for inspection purposes.
(We)ju gree m cove,indemnify and hap ha in an rot City of Cupertino against
Ut,IZ in CamOmmom Of .cosuang Of door etCory in any wYamruc aguvtseid City /
V z AcPLICANT orD granting ar this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 6Date 2>G
SOURCE REGULA710 �� � �
��/ Ki ro o Re-roofs �—
Sigamun,of ApplicalwConnomor Isom
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF �'-
wl by the puam m acture Municipal
Co aavpe ac,9.12.and
thandle hacoNoa material
u deRned by do Cupertino MUMctpal Code.Qapter 9.11.and dee Health and Safety
Cade,seetim 25533(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Y. ONO
Will the applicmt or form Wilding Occupant um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emiI harardnu,air cmtamieants a defined by the Bay Arta Air Quality Management all new materials for inspection.
District
QVu ON.
1 havemad the haadms materials mquimmnu underChapterfi.95 ofthe Califor.
nice Health&Safety Code,Sectiav25505,25533 aa125534.1 uMemmd thalf me building
does not covertly here.tenant,Wt It or my tapovihility tortoni Con mcapem Often
nuiUmMcros which mon to acct priorm issuanm O_fa Cenifcate of Ocm Signature of Applicant Date
Owner Ona smi .sem Da
All roof coverings to be Class'%}"or better