00040124 CITY OF CUPERTINO g I' a A1' a ,^ PERMITrvo.
BUILDING DIVISION, PERMIT',''. "•I '�O 'y l/I �a
BUILDING ADDRESS:, - . l/
SANITARYNO. APPLICATION SUBMITTAL DATE
O NFR'3-NAM..!Me / - 'S�71 T{vnO/Y _ _NIC CONTROL#
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Ili ARCHITEC /e GINE R
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LICENSED CONTRACTORS DECLARATION - -
I hcmby aRrin Her I am Band and«provision of Chapter 9(«mmn
mng, '." Job Description
m force
wiNSforce t00o)of D' wn3of Ne BuvneseaM Pofnesom Code.aM myli«
F:•t full and�zcfi«t �r �i«n � IIC
ing
=-/ � �2/ O � '�r n�"��JI�• � IC
W ee Class L
sl��//�77/�•.. ��'CI^'s"�
Convector m(�'AC a s ��!!
ARCEFFECTSDECLARATION ,. �Gg/ _. -".41/J E / gee;0
1 nalmsmM ms
my plshell he used n publicolcads f/
Licensed
Professional
^ OWNER.BURDER DECLARATION - -
z'Q 1 hereby aWe. he,I am exempt from the Control s Ligurian Law f«the '
F p fall ' g tea (Section W31.5.Business and Pmfevions Cade Any city or county
3G
which re,mies a permit m,mouserlalter,improv,demolish r repair any montere e Sq ,F[ FIOOr Area Valuation
Inner er its issuance also mtaims thapplim
the applicant for such permit file a signed ,
statement r
Natheislicenudpursuammthepmvimonsofthe Conunlo/s LicenmUw(Chaptn9 °•
(cammemmgwiMsem tOW)of Diviaion3of theHasrnur and Profaolon Codc)m - 'AP N Number'. Occu ane 'O, e
Net he is exempt therefrom and the brsis for Ne alleged eke phon Any violation of p �' }7 P
Section 7031.5 by any applicant for a Perot subjects the applicant to a civil pemlty,of D „O
1 mom than Ove hundred dollars(5500):.at
as awn.o(the property.ter ter employee.with wagesuNair vol,compenuum. r Required Inspections .
will doth,wma.hd tha m o man is nor intended or offered for We(Sec.9614,Business
and Profession Cade:The Contractors License Law does not apply to an owner of -
property wlm builds or improves thereon,sod who does such work himself m throughhis own employees,.pmvidd that such improvements are,not intended or offered for
We lf.however,6.building or improvement it sold within ane yenofemoplarogthe `
tr
wmr-huildcr will have the burden of proving that be did not build or improve for pur-
past ofaale.) r t
❑I n owner of the property am exclusively contomang with licensed comments an t
onstmct the project(Sec 7044;Business and Professional Cede)The Contrmm s L d
gene law does not apply w en owner of property eloo builds or Improves charter,and
who contracts for such Mjects with acona mmr(s)licensed prevent to He Cantmcm /
License Law'
❑Into excmJp�dorr See B&Pe.C'far this oeae'on O ,
.. owner��A " KBW Dae—F-R-Fzr� 0
j _ WORKER'#COMPPNSATION DF.CLAMTION
1AcrebY alErm under penally of perjury oto of Ore fallowing decluauon: Y ,
IhaveedwillmeinWnaCmiriB ateofConsentmmlf-ineamPorWoker'iCompen-
tion,es provided for by Section 3700 of the tabor Code.for the Pentagonal of the -
ook f«which this Permit is issued. -
❑1 have aod will common Wokei s Compensation Insurance,as retained by Section _ i -
37W of the Labor Code,for the penommce of the work for which this permit is issued.
MY Workers Compression Imuronce carrier and Polity number -
Curn.r: l 9 - - Policy No.: I '
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
•(Thio s«tramdnd bamal'Imd ifthe permit is forma,handled doliarv($too) n
m 1msJ _ -
' lcmify 0atin theperformanee ofthew«k far which this Front is iseud.l shill
Bat employ any peraon in any menet as me io nbjml to the Worker'Compm- "
smronlawsof Cal'Wriie.Dem � 00=. - ..
App
NOTICE TO ARFLYCAW:If,after making this Certificate of Emanptim,you should
become subject o the Wokcr'a Compenssrion provisions of the Labor Code,you must -
foMwith comply with such provision or this permit shall b,doomed rooked. '
n
' d
CONSTRUCTION LENDING AGENCY
Q Q I hereby alfirmrhat them is a comaracuon lending agency forthe peformantt of v
Z the wink far which this permit is issmd(So..300,Civ.C.)
Fy Lender's Name '
a > Landers Address
GP) 1 certify Chet 1 have lead this aPphcauon and mute that Ne above adcomwion is . .
-Py Q cbrt«t.I egret to comPlY with eli city mm cmnry oNinmae sod num laws relating te `
.V 0 buildingconemctim,and hereby authorise elprommultives ofths city to ooruponths
abovememioned propenY for mapecuon purposes .:
Lay F„ (We)agree to rave,Indemnify and koop hannlns the City of Canadian against
V InAnhtinjudgm,ru,command express.which may in any way mcmeagmnst said City
in conse9acnee of the granting of this permit. 1.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT _
'V y SOURCP REGULATIONS. ^ " !(�a�� 'U•• . ,
' /�- 00
Signature fApplicanUConuector
IIAZAregarr
MATERIALS DISCLOSURE
W11 Me-applicant or future building temporal store or handle hazmdouo ter l Re-roofs'
m d,fined by the Cupertino Municipal Cod,,Chapter 9,12,and the Health and Surety -
C�,Section 25532(e) - Type of Roof x -
. . ❑Yea ❑"P, - ,', _ •,
Will the mlicam or furor,building occupam use g,uipmentm,dg Ieps which All roofs shall be inspected prior to any roofing material being .
men Iarardm.air comamrmmsasdeEndbythe Be,Area At,Quality Management 'installed. If a roof is'mstalled without first obtaining an inspection
°`"""oyn ❑ I agree to-remove all new materials for inspection.. Applicant
understands and will comply with all non point source regulations.
1 have red the hamucous assumes rmoiremers under Chapter 695 of tho Cali- 4,
roma Health&Safety Cade,Sam.25505,25533 and 25534.1 understood that if the
'Fuilding d«snUs corremly have.teens,that it is my msponehility mnotifY the a«uPmt - -
of the Iwh'h al be me[pno so of a Can Se to
/g�ep` `7^/f Signature of Applicant - •;. Date.
- Owner A'eulhonzed agent - - Date ..
All roof coverings to be Class,"B"or better
OFFICE