00020095CITY OF,CUPERTINO -. ;,, '
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o '' .' ` PERMET No.
aoanmc orvisloN - PERMIT
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BUILDING ADDRESS:
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APPLICATION SUBMITTAL DATE
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ARCHITECT/ENGINELR ',
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LICENSED CONTRACTORS DECLARATION r-
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Description,
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I hereby affirm N t I 1 or made, p r o s of Chapter 9 (comment g
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with Smt 7")ofD" n3 fth"us and fe.imsCade .mdmyticenwis
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in Poll force and effect.-
Licruse Class - Lie.g
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ARCHITECTS DECLARATION
nde ttand mY Plans shall be used as Public re omb, '
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Licensed Professional
OWNERBUB.DER DECLARATION
I hereby Rnm that 1 am exempt from the Commences License L for th
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following mason. (Section 7031.5. Business and Prof n, Code Any ly or ro y
Sq. Ft Floor Area
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which requues a pe t to mutt , idtar, improve. demolish repair ny sw tort
prim tot issuance, Jr ail rts thovismn applicant for ughpemi's to file
fN CBusirofa Lt... as (Chapttt9
Nn he licensed Lt.. signed (Chapter
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"..at othe pmvnisi
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APN Number
Occupancy Type
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.(totem Sortum n3 fth n Cora) m
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and basis a y vrolati n of
. den he exempt therefrom and die bun for the alleged axe pi
Section ]031.5 b; any applicant for a permit ublems the,applicant to a civil Penalty of
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m more Nan five hundred dollars ($50(h
Las ownmoflhe propeity canny employees with waguu thmr ,olccompenumen•
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r, rRegdired nl pections _
will do the work, out th mrmurre-s not intended moffer ed for ade(See 7W. B timeu'
end Professions Code: The tractor'. License Law does .1 apply to an owner .1`4
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propooy who bull& or'- p th rcon, and who does such work himself m through
-his own employees, provided that such improvements are not but or offered for
'sde.Ifh vethe building amen moldvnthmone yeuof romple the
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of
will have IM burden of proving that he did not Wild onmpmve for pu
theb for
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1 r of the property. am exclusively netting with 1 need c nxact' to
cl N (Sri 7004 B ed Professions; Code )16 Contractor's Li-
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to pmlec ,
tense Law does pply to an owner of propenY who bmlds
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wh c n f s ch Prolccuw theconbad rt )Icenied pu nit the Convect r
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1 axe -e -S B& foythis on
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",BUILDING
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Owne Date
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' .,.,WORKERS COMPENSATION DECLARATION'
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f h by IEm under WnMty of pttjury one f the foll ng dedaraoom. }
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❑Ih ,end ill rm utn a Cen BC mofC .[,. selfma for Worker, Co.,."
'set n provided f by Sam 37W of On Labor Code, for the performance of the
work for which due permit is Issued
❑ 1 have am will mountain Worked a Compensation Imurame, m required by Section
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3]tM)of the Labor Code for the pertomence ofthe work for which th' permit is trained.
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My Warimes Compensation V=ffeen came-and Policy numb, arts
Cartier. ' - - "a Policy No,
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' CERTIFICATE OF EXEMPTION FROM WORKERS' "
' COMPENSATION INSURANCE
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" . pTnsecunnmed not b earruheted ifthe pemitis( crone hurdred dollars ($100i
or R.al
Ic`ertify that in theperfomance ofthe work fbrwhlch this permit is tuue6 l shill
not employ any person in any manner so as m become subject the Workers' Co.,."
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Applicant
NOTICE TO APPLICANT. If, after making this Ceroflcate of Exemption, yen should
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become aubjrit to the Workds Compensation provisions of the Labor Cade, you must
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fcnhwith comply with such provisions or this permit shall be doomed revoked.'
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CONSTRUCTION LENDING AGENCY •
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Ihercby aRm thu therenaconxtmemnl tiding egen yfonhe performance of
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the k for which This petmil re Issued l$ec 309] Civ. CJ j'
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Lenders theme
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Lenders Addrcs2
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I en f y tam I have read this a lice on d e enhe bo formation is
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comet. 1 8 t ply with MI cjq a Y nos and t ¢laws relating to
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builtlngconstruction and hereby auth nu rep a uof0 IY to enter upon the
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ebo a mentioned prepertY for inspection purposes.'
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(We) agree to save, indemnify and trip aamlew the City of Cupertino t,bumt
Iiebilitierjudgmems, costa and expenses which may in any way acme against said City
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m <onsequemc of the gmming of Nis pemit'
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APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
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SOURCE REGULATIONS.
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Summon, l'Appl' antlConvectm - Oak
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HAZARDOUS MATERIALS DISCLOSURE r
Re -roofs e
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Will the applicant or future building occupant store or handle haaardoua mamnal'
u defined by the Cupen o Municipal Cod Chapter 9 12 sad the,H MN and Safely
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Type Of ROOF ' - ' '
Code Section Z5532(a) ` -
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❑Yes 1,4
All roofs'shall be inspected to any roofing, material being
Will the applicant or mre budding pmt se equp tar dav¢ea which
emth d usabcommitmentsasrefined byth Bay Area A Qality Management
installed. If s roof is installed without first obtaming an;inspection
Distort
❑ Y<s No
I agree,to•remove all new materials for inspection Applicant
complyvith
un d erstandsr and' will all non point souree,regulations ,..
I have rc a elu matenab rtyurements under Chapter 6.9S of a Cdr
• (omie Code, Sectign, ]5505 255]3 and 25534 Menund that if Ilse
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huildmd hav le lent thin tis mY rtsponsib+( mnotifyt Faccuput
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of the Ic rot 1 1 9 cx fof 1 al[ f UP
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Signatdre of Appiicant ' Date
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gate ^ - Date
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coverings "B"
Alfroof to beclass or better
OFFICE
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