00020135 CITY OF CUPERTINO
BUILDING nDIVIDIVISIONPewMrr No.
DIVISION .. PERMIT CONTRACTOR INFORMATION: Z
dU1LDING ADQDRESS; -
SANITARY.NO, APPLICATION SUBMITTAL DATE
O NIiR' NAME: ., a ✓alt/` e
r N/C CONTROL#
/.CCHHIITE(TMNGINEER - WILLING PERMIT INTO
Rao ..y
H�5 SSo
Nzi
z y 3 LICENSED CONIRACfOR'S DECLARATION
O z g I hereby affirm that 1 mat licensed under previsions of Cbep,er 9(commencing Job Description
"
p v,t-u'� suit-SaGon]000)ofDivixion3ofNeBusinn,aid Pmfeuiom Cade,aM mylicenseis '' two
a I in full farce aid eB<m. 1 J -\res ��
axre nsDat a. New' f -
E O y U Licee Cleat Lia M ca
I-Ee O a ARCHnECPS DECLARATION
emroM "
} ' 1 mndmy plans shall be need a public records •,/ )- -
yQ, .�
laccnxed Rafwrotul
OWNER-BUILDER DECLARATION -
C Z I hereby T,.than 1 am exempt from the Comon,me,License Law far Ne
5 S o (-110x6-8 reason.(Session 7(13 1.5,Business and Prsfeaiom,Ile:MY city a county I
. m
which'najuim u permit to construct.eller,improve,de rad sh,or repair any a meme,
pd-Iona iseat.-a-she"uias the Witicent fntsah permit to rte&signed statement sq. Ft J1F16or Area Valu io '
Net he is licensed Panama to the previsions of Ne Contractors U...Law(cMger9'
that he I,eng with ieserm n end of Division3 th ad Busieasand..A,vi Cadelor
Nat he is 313 b Nacfrem end the bazar for the ailcged e,<mpei,to My,;Penalty ser APN�Vulnber' Occupane Type
at
Seen-70313 than by any ape 1.11 for(a prmdt objects the applicant m e civil Penalty of (D
Qt mart Nen Eve hutdrtd dollarx Ig5a0).' - '
=1,a owner of the Property,or my employees with wages ar their sole competencies, Required Inspections
'wdl do the work.and them n'turc seat i eendedu,offered fsriale(Sec.1041.Bsin
as.
end Pmfe-mrai Code:The Com etar'e Liam.Law does al apply to m owner of
pruprny who holds ca improves thereon,std who does such work himself on,through'
his own employees,provided that loch improvements as on,immwed m offered for
We.if -wear.the buildi-g or improvement Is sold within one year of complains,the
'own builder will have the burden of Pmvidg that he did trot Wild a improve fur par
Po ofale.).
I,u owner of the Property.an exclusively connecting with becrand conuenms m
ct the Prejecl l a.]ON.Business atd Professions Cade:)The Comminutes U. { "
„ cense Law dee trot ly,o m owner of property who builds 0r imprtvex thereon,acct .:. '
who. r. pmja.w"b.c nacmr(O Ocenaed paramedic, Comncmh
Liana - t
❑tem em a ,B& far N' a _ fl
Ow. et
.. RNAt��aYJ
WORKER'S COMP SATION DP.CLARATION
n 2b .Bd-m-d r AUG 2002,'
Y penalty O,o Comer,oflIf-mmwiogdalatasiau;
Ihave end will forbyveCion 37 rc ofComer, Code.for'hen e
Wodchce of the
pion,r provided Pe mi Section 3]00 of the Labor Code.(or the pedomunce of the
ork for which this pcmd,is issued. p,
[31 have end will maintain Worker's Compensation Insurancerequired by Section
00 ,a x. �u'LD11k,
1tl^
Pen ,
3] -f the Lobar Cade,
for the performance of the work far which this permit is issued. ' d
M Work
ars Com null
Y on lnm
_ pc see carrier and P-lir
Yumber art.
d
i Comer. '
Policy No.,
'
CERTIFICATECOMPENSATION
INN FROM WORKERS' '
COMPENSATION INSURANCE r
' '(This section need at bedomPlaedifthc pemdt is forte hundred dollars 13100) s
s.
Ianify U.sin thepeAarmaxe tf thewek far which this pemul is issued,I Nail '•
rot employ any person in my manna so as m become subject to the Werama Compr h.
sell--Laws mu.Data
1:
-
Applicant - •_
NOTICE TO APPLICANT.IL after making this Cenificem of Exemption,you should
me • +
hecaobject to the Wurkeec Compensadon monsic a of the Labor Code,you mon
fam with comply with such Provisions m this Fermii dull be domed ravaked.
CONSTRUCI'IONLENDINGAGENCY x
Q l here by Mrm Nn Nem isdnmclemdinpgency fa,M perfomunce sf '
the work for which thio permit is issuweed 6 a..30109] civ.C.)''
C'.>. ndeer Name
rr L Leedeas Address
4. 1 certify that 1 have reed this lion d ret the
above infortmtion is
Z conal.I agree m comply with all c y and coon ire nes and sate lows inlet m
building conswcuon,end hereby an "u re rcnutivn of this C.7 pity mercer upon the "al,64-mentioned pmpeny for inspection purposes.
�• E. (We)ogres b ave,inchromfY and kap harmless the City of Cuenire apirst .
C.) liabilities,judgmen.,cm.and espartos which may in any way acma.ghm.mid City
>a W incoddquenec ofNNE STAN of this WILL + Q
VF SOURAPPLICE REGUL IIONSND$AND WILL COMPLI'WITH ALL NON�POINT - ✓ .. p/� l7 '
� SOURCE REGULATIONS - ,
Sgn"nuWrt•iollfimdowwr
he applHAZADOUS MATERIALS DISCLOSURL Dae �/ 1�:?ry A, UCC—,'CGI
cm,
or baton,Wilding acaWt score a hadle beem,at,manrid Re-roofs
az dcfineJ by the Cupcnimo Municipal Code,Chapter 9.12,atm the Health and Safety
Cade,Sade 33332fa)1 - Type of Roof -
❑Yes o '
Will the.,Ii.,orI. rcbandineserupmiuseeymipm drord W eewhlrh All roofs shall-be inspected prior to any roofing material being
emitict? us air comami?."�mr
fined bydwBay ArteAvQmaiityMmegemrnt installed. If a roof is installed without first obtaining an inspection
Dis rB
oye9 ' " I agree to remove all new materials'for inspection. Applicant',
IM1av . darcgmiremmr.nnticrGWP. 5193afNeGVi- un erstands.and.will comply with all non point source regulations.
rani.H & code,seed sus,23333 aM 2333x.I u and Nat if Ne
building s a ly heve e n e,it is mY responsibility miff pare
of the m I riCcni I of c sy
.Owes,- whoriaedagent - ignature of Applicant Date -
oat t
All roof.coverings to be Class"B•'or better.'
OFFICE