00030109CITY OF CUPERTINO-
umLDmG DIVISION , PERMIT
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BUILDINGADDRESS:
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APPL�0 SUBMITEN DATE
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LICENSED CONTRACII)R'S DECLARATION
1 herrn' .morin that I an licensed under provisions of Chapter 9 (cimmuming
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r ARCHITECTS DECLARATION '
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.. 1 urWerstend my plum shall be sever u public records. -
Licensed! Prof ..raw
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OWNER -BUILDER DECLARATION
I hereby .form Net 1 ate exempt from Ne Contractors License Law for the
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following me . (Sectim 9031.5, Bminess and Prof ion. Cade: Ar city ea marry
Sa Ft. Floor Area
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Valuation
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wMch reclaims. t m construct, alter, improve, demolish, m an trucmrc
mqu perms Pia y e
as air
pd., ro ismcenod Wantwmetheapionsofut o Corosuch muuaril wUw(mtemwt
pmv.ionsaf thaCmtrwtessand ense
dietheislicewit pSecond
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Code)
(commescexempth Section ]000)de Divisum 3 of the egad Business and onProfessions yiCode) or
that he is exempt eM the burs for alleged exemption. Any violation of
AFN NDmher.
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" Occupancy TypC
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be
by any reptant tea a gamut subjects the applicant to a civil pet,ltY of
any Vph
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not them
ea mote Nen Ove hundred dollar (3500).
❑liar owns o(Ne property,eamy employees with wagam theiraole comat,.von,
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Required Inspections
will do me work, and Ne sttacture is not intended or offered for ale (Sm. 9014, Business
and Pnef.11m. Code: TW Cmeacrora Lianse law dam and, apply to an owner a
property who builds or improves thereon. and who does at work himself or tmens,sh
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his own employ.., provided Nat such improvement. art col inmulm or offered for
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side. If, however. me building or lmprovementis cold within can yearofcompledon,Ne
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ownerWllder will have, the harden of proving Nat W did nal Wild or Improve for pea-
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pose mmale.)l
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El 1, u owner of ilia aapeny, un exclusively cmvuting with licensed Ionerachas ro
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mnevum the project (Sen, 9000, Bu.l••=. and Protestant, Cade:) The Convectors Li-
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rise law dura nm apply. an owner of property who Wilds. improve. NAem, and
wWonfleacsforwchprojwmwiNacon=to0s)licen"punumtwft Convw I
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Lt.. Law.
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❑lam exempt under Sm. B &PCfor Matson
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Owner Data
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WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of arjury roe of the following declueoou'
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❑ lMwaMwillmainWnaCenificasof Conunuoulf-insumfrr Wmker'a Conran-
atirm as provided for by Secure 3700 of theLW, Cade, fm the performance of me
w rk for which this permit is issued. 'x,
�fJ I have ¢lid will maiman Wedmf, Corepolatim Insumce, as required by Section-
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•3'/00of thelabor Code,fw Ne perfomarae of me work for which Niv permit is i¢aued.
^ Workers Compenution lneurame curimPolicy number arc: ,
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CBRTIFlC OFPROM WORKERS'
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OMPE SATION1INN
• ' ' COMPENSATION INSURANCE
(This.eetinn mednm WcompleledifNeamutix formehuoNed dollar 13100)
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IcaniFY Wtin Neperfomanttof meu'mk (mwhich NispemNisistued Lhall
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nm employ any pemm in coy manor, w n m Wwme wl;.t to dm Worker'
nationConran-
nws of C.lifGas,
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NOTICE TO APPLICANT: IL after meting Nia Certificate Exemption, you
u.1sould
m must
become e..t the Wodmrs Compensation prmiitihal of the Labor Cade, yeti must
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foMwiN comply with such pwvisims m this permit shall W deemed revoked.
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CONSTRUCTION LENDING AGENCY
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I hereby affirm that Nam is a construction lending agency for the p.f..a of
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the weak for Which this permit Is Issued (5..3097, Civ. C.)
Lenders Name
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Landers Addrmi
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L certify that I have red this application and sum that me above iNnnessU n is
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correct. l agree to comply with all city and county ordinances and sate laws relating to
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building comtmcti and hereby authorize uprcammtives of Nis city wens, upon the
above-mentimed property her inspection puraees.
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(We) agree in uve, indemnify and keep harmleas the City of Common against
Iisbilities,judgerents, costa and eapenas which may in my way amemagainst mid City
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in consequence of Ne granting of this am h. I+
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APPLICANT UNDERSTANDS AND WILL COMPLY WITI I ALL NON -POINT
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SOURCER/jyas,''Un N5. �
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FIA7.ARD0 5 MATERIALS DISCLOSURE
Wifitim. plicenl orPom Wilding occupant ¢taumhaMlehaWous masnal
Re -roofs
as defined by the C.Kmim, Mu pal Code Chapter 9.12, and the Health and Safety
ROOF v t
Cede, Section 25532(.)+
,7 Type Of
Will Ne applicant or fulum Wilding occupant use egmpmentor devict, which
: All roofs shall be inspected prior to any roofing material being
-a inspection
emu hacummUs air conumimans as defnesd by dm Bay Arca Air Quality Management
installed. If roof is installed without lest obtaining an
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tunics? vim.
I a ree to remove all new materials for inspection.' Applicant'
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un erstan and will comply with all non-poigsource regulations.
have aaatheh:aa amatenat,rcqimm Ghap d.95afN Ga i-
famous Health & Safety Code, Sections 25505, 25533 and 15534.1 malaymnd that if the
building dorso lay he'. ...at. that it is my rexpondbility to notify the o.upmt
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of Ne¢qg�ertG'� th t prior w issuance of a Certificate of gqetese a�qeey
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signature Applicant ', ''Date '.
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own reuNonzy Dal
All roof criverings to be Class B or better.
j_ ' OFFICE .,