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00020074• aq 4 - CITY. OF. CUPERTINO • BUILDING CONTRACTOR IN OpUAlION: No... n .. DIVISION PERMIT , . QPERT 0 ©L OQ.1 4 ' BUILDINGADDRESS g•, SANITARY NO. APPLICATION SUBMITTAL DATE -- /� /a`l c e7 ©. i i v .i OW /NEIt•,5 NAME: 7`t ,L A �i � /1' I I I fL { � N/C CONTROL« •r I. I ' "i. .. . E J .:. , .PITON �� � ll a (l0. ✓ J �� 1 .'� ARCHITECT/ENGINEER, 1r PERt,1 " Ij9Ft) . �00 " • ^. S� P - 'LICENSED CONTRACT'OR'S DECLARATION OZ�O F 1 hereby affirm Net 1 am licensed th der pmvrsmns of Chap 9 (comma cmg um with Sc 9000).fntvaton 3 ofthe Busmm m sand Profnsto Cade andra license is y , Job Description, • -- I " O ,• i. full fome end effect. .e - ;• r f / • I �, �U Lice class Lip.M : :',1 ,`,. ., g Date bonrracto - ✓f /t • 4 - .1 Y.. ARCHITECTS A E CIS DE(2LARATION .� In bindery plans shall ba used u public records I. Wce dPrufessiaml" w - - OWNER BUILDER DECLARATION _ C 1 hereby fFw But 1 am empt from the Contractor L'ct L w for the _ S toll 're son (S t ]831 Bui sass end Profevssone Curie Any ty or w ty F. + Q " •• ,a rL a which rcq coin perms m liuct alts mprow dam hsh Tali y awcnae a s F[ PIour Area q' - "Valuation prio to its es, c ots rcqu ms the apple tf a hper3Ntto fleasg dsmtcmeni thath 1 setl pu ua tbN P on ftheC -tr treed L (CWPter9 ° ` (cumin ingwnhSecti n7") fD inn3ofsheBossine ssandProfessionsCode)or that h mpt th.ref d bas's for the alleged exemption. Any violation of - APN Number . O upancy Type • Sac. n 7031.5 by by adicant fora pemot subjects Ilia applicant m a cinl Penalty of - i,' - 3 - / nm more than five hundedd dollars (S500). - ❑J.as owmi of dm pmpeny,or myemployeci with wages es their sole compemuion, - - ° " -.'h� Requir8d Inspections + " { wtlldothcwork,hnd Ncsw nurcts. oH. ...dedmoReradfmaalesm.7(44,Buaimas and Profua Code The Comm�ors Licenu Law dos nor apply t an f )'a { P - 'Property who Wilds or improves thereon. and who does such rk h tf through / r 3 his ow pf ye pmvid d flan such tmp...'s are not intended oB red f r , sale If owe thebaddingonmpmwmemusold wthm on y icotnplu on the ` `� 4 oowm will hew the bvtden of prov gtht hedid not Wald o p -for Fa ' tr f i�l " oltl u fWe..) Y ❑ r of the pmpenY ass exctusry ly <ontracon8 with I ensed < .-.tots to `� - e protect (Sec , Business and Pmf m Code) e C wnm' Lt - mnse Lew does tint apPI an owner of Pmpeny who builds or tin roves thereon end v whocontra,ts h ecrownhac tm(Olicensec,rmatm noWncYe. `Lice Law 's -❑ . t latnex Plan B& C o Owner Dam WORKER'S COMPENSATION DECIARATIO ,4 yt' k' - (. ,• + IhrbyaRrmunderpenNtyofperjuyomo fdrcfoll.w gdml liom:- .• ) 4` - „ .' ❑Ilia dwill mntamaCentficate Of Consent to self -mss for Wakar'COmpe .. " -I satin o pov d.d fed by Section 3]00 of On Labor Code, for the pelf -anon of the work for which this pewit is- ssuad. - - f - ❑ 1 have eM will mammin Workers Compensation Instances as mq d by Section COdefor thepertcecanttof thework permniiiesus,d - - - ` s ' MY Workers O number are: MY Workers Compenvwn Insurance carrier and Policy numhr arc: . : y Y • ' -t' Cerner: - - .. - , - Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS'.. COMPENSATION INSURANCE (This section tmedtmt becorripletol this, pewits foron, hundred dollars ($100) I,an rectify thntnthe ofthe permit ikshe . Cahill n any an ii. any manner so as m hcwme Subject w ths, W.tkers Comps - - - fi.a L.w ofC.non ,salon Lewsaf California. Dare f t NOTICE TO APPLICANT: If, afmF nuking thi3 Cenifinm of gumption, you should become Worker's ' - •i 1`' • subject ro the Compenmuon provino.x of to Labor Cade, you must - - fonhwithcomply with such provlaions or this pewit stall b. deemed revoked CONSTRUCTION LENDING AGENCY �� Thereby off that Mete uecansrmdnlending eg.ntyf thepMorrnvmeof y'' the work for which this panda rs mused (Sec 3119"1, Civ. C.) Name t. ij •' - - t,(~,� 'ai d '4e r ,.:'e ' - ' - Lenders Addmae - -. • • .. • " I cenify rho I have is ppl' ai nil sine details above infommoon s 0' W' n - a Pr z cowct I egrec m it ply' with i w 'nantta and sin¢ laws rcmting m s , n $• 1,r - `•,' - t t, V building,.., -coon, antl here ya o u e moves of this city wenterup.nthe 'above - - 0 fa: "F mentioned pmpcny for mspecu Purpoaes. (W) sire to rove, keep bumless City 9 ' mdemnifY end the of Cupemn. against U , Ilahilioesjudgna6la, costa and expends which mayinany way accrue agnnsi mid City • 7s fri to consegae.ce of the gram '6 of this pewit. .., ., - _ F APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON- POINT' e'��r �a •iU 1 SOURCE REGULATIONS,•' _ _ S GG a� F. _ `lO /�,�'• /�/ M /71J�L1:CC_ .., '�/T� •. . l� I IV l.- M 1 Signature of ApplicanUConaectm ., ." Data } HAZARDOUS MATERIALS DISCLOSURE ^ Re-roofs Will the, applicant or future building roup rt or Handle haaotdaus ineseriaP as defined by the C pert M I Cod Chapter 912 and the Dentinal Safety code sect zss3xar e Type of Roof. ^' ' El Yel f Wirth OPlcantorfuwrcWildingcepen ,useegipmentrdevtreswhich `emtthauM"- All roofs shall be inspected' priortoanyy.roofmgmatei'ialbemg' an,..mminent3 egncdbytheBayArcaA v airyManagemen .installed.'If'a roof is Installed, with out first obtaining an inspection„ District? '', ❑Yet._ .�- ` . Iz Tee to remove. -all new materials for inspection Applicant ' _ _ I have rand ha tl materials Chapmrfi - understands and.will comply with all non point source regulations.: mq mmenm abler Saf m. Dolt -' hem. Health & S ty C mio.s 25505, 2 33 end 25534. I. uM then if the - s building doe t dy a nest, i mymsponsibilirym f the mr - t - • . ofterequiremn which st m r i s c 'fic Mee/,7g,„,t _ gnature of Applicant Date utho zM agent. Date 1• x.. ,Owns - ` All•roof coverings to be Class r "B:'.or better OFFICE 3.