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Home My WebLink About00020104 CITY OF CUPEN O, .lJ PERMUTING. 80IDINC DIVISION PERTCONCRACTOR INFARgATIONcQO2DJ O ,4" , BUILDING ADDRESS - s /•' SANITARY NO. - APPLICATION SUBMITTAL DATE 5- S, '6 �cJ 3.J '� WNE 'S NAM ' - ".N/C - - CONTROL y' ill PHONE: f r 1- Gi ©• . 53E7® ARCHITECT/ENGINEER - BULD3N P 1IT INFO S 4 G ¢HLICENSED - . 0 r Lrmmet let. DECLARATION' 's' -1" z o p� l Thereby affirm met I I anal an❑er p ' ons f Chapter 9(wmmenang - Job Description pz.t-u1 wish Section 7000WIN,istim 3 fthe Business sand Profeumn Code,and my license /w�� Infdlf laroll effect. ^..! Y / � • ' /7 ,f 1`n y, 1p! x rY �'�r ex u� Lic n eCless Sum -Date Coan¢mr -' ,. l' ARCHITF,C'I'S DECLARATION } 1 uncle lend my plan hall be used a public records ii�.0z Lic sl Prof meal• ., //�{(L OWNER BU rcpt from she Contractor's r� I hereby so ,affim(Sm on 1 an exempt from she Conaamrs s License Law for';he }ex �. following .(S con]ous5,ct,chaa and Profeamons Co de Any atyacounty - x - 6 3= -which 11 126 perms m cowwd dmr, mprove demolish pair any ewcture Sq:Ft. Floor Area > - Valuation " prior to its i e,also respites the applicant forsuch pamitt file a signed site ent „ That hes licensed purauanno tha Tmenuonsof the Connwcto/s License cas,(Chapter9 y . - _ v (jp d ' " Ico- ngwiNSection7(sfa fDisinm3ofineBusinessandl4 fes eresCo.,.. APN Number 1�: Occu T1 e- chat he' xempt,therefrom and the basis for the alleged exemptionAny violation of ©• / Pane,Y ]P, Secdo 103 E5 by any applicant fine permit rubimts to,-,In 'I vil penalty of not more Nan five hundred doll.($500). a ., -. E]1.as swam ofthe property,or my employees with ma wages at. r sole cominandion., . - I ` _ Required'Inspections' . me w ' will dollar, and construction is influential oroRerl for 1 (Sa:1044.Businu and Profession;Code The Contractors Ltanse law costs not apply to an oxine Of „ d property wno bull&ar improver merest,and who does inch oh him a through" �B r�® s • a e„• :} his own employees Provided that such Impmre tovee is a 'not nodded or,oHere❑for • �a y sate.If,however.the building in smpmvement is sola within one year ofcomplehon,the ' - t•, r builderw life Ne Wu ofpiovmg Nmnedid of ldorimpraveforpuf-, JAU I/� :'v].t n 5c Of 60le) S. • - Or .2001 • .. , ."mon"o f the property,con exclusively contracting wish licensed convaami to co ct the project(Sec.1044,Business end Professions Clef The Cormecer's Li- .• "' t cense Law docs lw pply to on owner of property who bolds onmpmves shereon,and y - •.BUII.DII{I i 'wno contrec hpro3ecu wlNeconuvtr(7lbensedpursuernm me ConuectoYs _ License 1.m em m r S B kfar p ed * ' Owner WORKER h1PENSATION DECLARATION , ! ' . I li teby eR under pmdty of M 1 ry f m<following declvatimis e I ll t- t •D Iheve d II min a Cemaa fcof Con m st salf-imm6 fm Wmise.Comap -aat .pm ded far by Sammi 37W of m Labs Cade,f theNofornnm f the r - work f ti per h luta val ❑ ^ r k f D 1 have ❑will'ma m Writer's Compensation lummance,.req d by Section 3100 ilon LadicurCods,fix me perfomwnce ofine workf which this person is intrand. ati, 1 MyWroe Conapensation Insurmsecarrier and Policy nucclarraus, f Comer - Policy No.. CERTIFICATE OF EXEMPTION FROM WORKERS " , I`I COMPENSATION INSURANCE - 1 1• I' (Thi sect n media he completed dine limit is formse hundred dollars($100) x. or leas) I crt fir lhelmmeperfoweaeolme work for which sh�s perm,ren rsaul l hall 2 Y ,-•• _ . not ply y peons.in any man manner so as to become subject,to me Worker Compo l ant La sof Celifms Dm' APP! t , • .. NOTICE TO APPLICANT If, fit,making n s Certificate,of Exe Poon You should -+, become subject t m Wormers Compensation pmnsmnx of the Labor Cle you must forthwith co ply-with ch provisions or this pewit shell bed l tevokl `'• r r CONSTRUCDGN LENDING AGENCY •s ! f F E Ili by affirm that Nen' a construction lending agency(nhepMowance f • ' .N f ' 'wo the work for which this pewit is iseul(Sr.3097,Cis.C.) 't- ey i,y Lendels Name •'r - 'Ona > Lenders Address L:a 0 1 candy Nm I have reed 'a pli tri d site mat N above infomution Is -f - currem.l c to coin 1•with 1 an c ordine ces and sme laws relat ng to ! 1 ?ere v r r •� 'Z bold gco awcdon,end here author p senmfives ofmucry to ester upon the, ^ " U'O .b. f dprolcrtY fir mapecuon trusts. 1 W Fa (We) S.to save,mdemtidy and kap Thornless the City of Cupertino against 4.7 lieb 1'ties lbdgme t,costa and expenres wh ch mayinany sene.crounagaironsedCty, •4�� ('] ',r/ �a r� in consequence of me flooding of Nis pewit. ' APPLICANT UNDERSTANDS AND WILL COMPLY WITH AT I,NON 1'UMT _ 'A•., , U•,z SOURCE REGULATIONS. Signorina ofAPPlicanJCornmorr• Data HAZARDOUS MATERIALS DISCLOSURE y NU W❑I mea licant or fuwm builds cu mtmort or hanmenazerdous lumenal, 11 s• ° " pp gnc P Re+rOOfS as defined by the Cdpcemo MummpehCle Chapin 9.12,and the Health and Safety s. Code rubes zss3z(a)+ �f�/y'� Type of Roof. •" GWOsheepplcant of wmnailai goccupmtuseeq ip htnrde.i�enwhien Alli''ofs shall be inspected prior'to.anyy roofing,material being mail haLlydea,an onmmm0nts .dell by.the Bay Area An Qunlhy Management installed. If a roof is,lnstalled without't�rst obtaining an inspection;:. n, I agree'to remove all new rrtaferlals for inspection. Applicant," DYes. T` I: d .. Ihav �� ehvsd amaa❑da corn a drChap 6.95nrsh Call- un erstands and will, Triply.with all non point source regulations, requrm 4 A "o.•' s Toni He my Code Section 25505,15533 and M.0 I nderstand Nat d the building rlyheve thiinn'reiparnibilit tonally 1. 1 7 :"1 f �ofthe tuor t t y��o�xT aof.0e as , M erl uyt PI/U Signature ofAppllcant Date Owner or andoized agent ��//UU Dale _ "m "^ All roof covering's to be Class"B"or better ' ., , ,., ..,. ^ ' OFFICE'' , .