00060174,.,o4
CITY OF CUPERTINO
F BUILDING DIVISION - PERMIT.-
PBR No. -
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BUILDINGADDRESS:
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APPLICATION SUBMITTAL DATE
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ID
0E0174
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OWNER'S NAME: ..
cord Sccnon 0000)"fD yion3 of Me Busmeis mdfeset��� yli«
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ARCHITECT/ENGINEER
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LICENSED CONTRACT'OR'S DECLARATION
'lions of Chapter 9 Ing
' " Job Description
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I hareby arcrm that 1 am licensed order pv� (comma
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cord Sccnon 0000)"fD yion3 of Me Busmeis mdfeset��� yli«
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full force and effect r/
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ARCHffBCT'S DE TION ,
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1 understand my plans shill W used as public records
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OWNER -BUILDER DECLARATION ,.
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1 hereby affirm that I am exempt from the Cammetors License Law for the
following resume (Section 7031 5, Business and Protisamv Cody Any Cry or county
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which requires n perms to covwm, after, improve, demolish, or raper anYaimccn.
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'pitto ba issu«, also requires the applicant for such Permit W file a signed atamment.'
Nat he is licensed pursuant m Ne provisines of the Cmneractors License Law (Chapter 9
fammmendng wird section 1000)arlRvinianJ arthe Baai«a nerd l'roresnmm ede)ar
APN Number
Occu ane
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that he is exempt Nerefmin and the basis for the alleged exemption. Any violation of
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Section 7031.5 6 an applicant for e t mb ab the applicant to a civil al of
Y Y Perini j PP .Pe" ry
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pia ream Nan f ft hundred dollars y employeessoloS., corripeeeadon..
❑Lmownerk, Vin property, or myemntendes
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ed of owagwvthe(
the to00, Business
will Bothe coons had the avr
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Conti doffs License La doesred
net apply
.and Professions Code: The Conmaors License 4w docs pia apply ro an ower of
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property who builds a improves therecn, and who does moth work himself or through
"hie
304 = r ROUGH ELECTRICAL - .
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own employees, provided the provemenu ate not intended a offered for,
ale.If, however the Saildiag or improemenns sold within". yearofeamoletiomme
'501 . — FINAL ELECTRICAL' ENERGY -
er-builder will have the burden of proving Nei be did not build or improve for pita-:
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5iD5.— FINAL ELECTRICAL
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ower of the property, am eaclussvelY cano-ecun6 with bcensed cvwcton to
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cumtruct the project (Sec 7016 Bminess and Professions Code:) The Contractors Li-
an of property who builds or rmpruvex Merton, and
ce pie Law does nut apply at owner
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wh «tincts for such Prol wrthecontaaoNgly:erased punuanstoshe Canuacsors
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Li.o. Law.
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- WORKER'S COMPENSATION DECLARATION
lWerby.frin dalfel
Ihartbyaffirm underpenalty oeperjury oneofthemane mgdeclan'S
ofof
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wnaCemity
rcfarWorkera Compel-
Ihave Consent to CO
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cation, as provided for by Section 37W of the Labor Code, for the pert miance of the
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work for which this Permit is slued.0
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❑ 1 have and will mins. Wmioe a CompemflO. Insurance, gmtd by Section
3_or Neto ar Cotle Por Ne performantt of,be work for which do. permit is is sued
,My Wmkers/ h tuna end P91rNTegIIIRiE✓ e' '� O S
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CERTIFlCATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE -
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(This section neetl not becomPletdifthe Persm'I is faro. hundred dollen lS100)
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marmm me performance ofthewakf« which Nitpemdriaisa'Corn hill
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not employ any Person ua any manner so art to became subject to rhe Wmrken Comperi--
setionuwso(Celifomia:Date
Applicant
NOTICE TO APPLICANT: If after making thin Car ifrc"rc of Exemption; you should
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become subject to the Weiser's Compensation provisions of the Labor Cede, you muss'-
fmthwith comply wird such provisions or Nis .it ahall x deemed mvokd.
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CONSTRUCTION LENDING AGENCY
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(hereby affirm thin there is acomuuciron leading agency for the performance of
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- the work for which in. permit is issued (Sec. 3097, Civ. C.)
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Lender's Name
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Lenders Addmae
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1 certify rhe 1 have read this application and spire that the above information is
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correct 1 agree tocomply cord ell rosy erW county ordihan«s and sure lewa relating m
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'UObuilding
cmismctimi and herebyausbonea rcPrcmnehose of this city m arm, upon the
fir F.r
above-mentioned property for mpectom purposes
(We) agree on ave, mdemmdy and k«p hannlms the City of Cupertino agamt
Ilebiliors,judgmenb, cmtnand expenses which meymany wLy..nMagaimtmid City
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in consequence of she granting of rho P r
APPLICANT ❑NDF.RSTANO aND ILL COMPLY WITH At.[. NON. INT
M 'IONS
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illignaturc ofAPPli«n mrecras _ Date
HAZARDOUS MATERIALS DISCLOSURE
WilldmapplicantorfutureWildingoccupantsnieahanNehazardouemaredal
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Re -roofs s +
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as definrd by the Cupertino Municipal CW;, Chapter 9.12, ad the Health and Safety'
Code, Section 25532(a)t - -
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Type of Roof
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❑Yui ❑No
All roofs shall be inspected prior to any roofing material being'
Will the applicant or future Wilding«.pmt use equipment or device; which
is first inspection
_ emit beurdousair contaminants as defined by Ne Bay Area An Quality Management
installed. If a roof installed without obtaining an
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Yes Ll
I a ree to remove'all new materials for inspection.. -Applicant
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understands and .will comply,with all, non point source regulation's.
/n 1 have read the haurdoin reatenals u under Chapter 695 of Ute Cali-
�gtiimmen
form. He'll, & Safety Cede lion 505.8577 read 15536 I understood that if the
building doesna cimemlyhav te this' 11=1 ibrlty m narfytheoccupant
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o fins hrch mujsr/�pr= pit r issuance of aCrffate ofg ye Y
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.I \ <Rotor
Signature of Applicant Date
kor author � Date --
All roof coverings to be Class "B" or better
OFFICE ...
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