B 0606 CITY OF CUPERTINO
(WILDING DIVISION PERMIT CONTRACTOR INFORMATION:
Bulli INc,_nuuRl 4— r) Penton' re/ ^/
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1]WNER'SJ �S a � at#/� APPLICATION SUB DATE
rNIONE: / / /�;6Vllp• ^ SANITARY NO. CONTROL NO.
❑a 2 ARCHITECT/ > ^ BUILDING PERMIT INFO
Vi MECH
2.
v voNi Z I,ICI:NSED CONTRACTOR'S DECl.AIZA'1'ION Job Description
y,�•_
o Z_ I huchy:diirm that 1 am licensed under......into°f Chapter,9laommenemg p
mFo�u with Section 7(xNl)of Division 34 the Businessland Pndus.ivns.Cala,vnrinry licevse
is in lull force and effect.
ca I.idcn.se Class Li,.p � �� V
B ow Ilam Contractor
v ARCHITECI"S UIiCLARA'1'ION
'F'=°g 1 understand my plan—hall W used m public records
Edi
vi,u20 Licensed Professional
c w o OWNER-BUILDER DECLARATION
1 hereby a inn that I am exempt from the Comnnor's License law for the
t"?S� follow ing coach Section 7031.5,Business and Professions CrcR:Any city or county
Sd F v
voliish requires a pareart toconstruct,alter, p demolish,Eio repair any structure
dSaa
proor to itsI. requiraxth ppl ic
car for suchpenult I tile .g J Dement
ohm h licensed pursuant fl p I the( t s4. e License L (Chapter) 5 t. P O F�[,ea �jl{IHIK)Il
(n. n 6 ]hS r ]11,1(1) the 3 urs B . dP !:. nslut ra �/..`/)
orS lh opt rh nandothe ht f t e06e10 pt Ayviolatinn
of Ssut o r e Lou iv u Iy applicant fora per nn mhleem the upplmum In n civil pconh
m'millet°rathallnaenardndatdmrs(ssom. y APNNumber
Occupancy Type
D1,as owner of the properly,or my employees with wages as their sole compensation,
wi do fire work,and the mmarum is not incurred or ousted Rrr sale(Sae 7(w. 'Required Inspections
Business and Professions Code:The Contractor's License Law does not apply hs an
owner of property Who builds or improves thereon,and who dr es such work himself
or through his own employees.provided that such improvenrencs am not intended or
offered for sale,if,however,
rhe building m improvement is slid within one year of
completion,the nwncry Wilder will have the burden of proving that he did not build or
improve for purpose of sale.).
D 1,asinner of the pmpeay,ton exclusively contracting with licensed contractors to .
construct the project(Sec.76m, usiness and Professions Cloth:)The Contractor's
License Luo,docs not apply no an owner of pmpeny who builds or improves thereon, '
and who commas for such projects with a clamorous)licensed pursuant to the
Commemr's License Law.
D 1 am exempt under Sec. ,It&P C lin this reason
Owner Data
WORKER'S COMPENSATION DECLARATION -
I hereby a0im.under penalty of perjury oncol the litlluwing declarations: ,
] 1 have and will n ainmin.a Cruleme of Clown, ,,seltolum for Worker's '
Compensation, as provided for by Section 3700 of the Labor Coca, for the -
Perfnrnumce of the work for which this p omi is issued,
°1 have and will maintain W'orker's Compcnmtion Insurance,as required by Section
37(1(1 of the Labor CWe,for rhe performance of the work for which this pemrit is
issued.My Workers Compensation Insurance career and fall you rare: -
camert P
CP:RTIF EMPTON PROM WORKERS'
COMPENSATION INSURANCE '
(This section need nor he completed if the permit is feature hundred dollars
(S Im)°,Ins,)
1 cetil'y(hut in the Pufonaavee of the work for which this permit is Issncd,I
nhllll nal enrpiny any Jp��/yy �n nDer set n<m leant.svhjecl 1°the Workers -
pvmmion%yug�'S�I0ale
Applirmt %-7�
NDTICI?'T :If,after making(his CeniOcumuf Exanption,you should
becomeor,, oiler's Compensatioatini
n pr - ons of L
luhnr Coda you most '
0 fun hwi lh comply with such provisions or this permit shall he deemed revoked
CONSTRUCTION LENDING AGENCY
0.. ' I herby a1Rrm that there is a construction lending agency for the"mmmuce
or the work for which this permit is issued(Sec.3097,Civ.C.)
L Q Lender's Nun. '
I0.) Z lender's Address
0 1 cenlfy that 1 have read this application and state that the above information is
[.y cocall.1 agate m comply with all cit,and county onlimances and state laws reining
0 U u.bolding construction.and hereby audience repmsentmives ol'thi,vity to crier cram
the above-mentioned property for amoestion peopmes.
F:
Ac 01 agree to save,indemnify and keep harmless the City of Cupertino against
.w ret liabilities,judgments,costs and expenses which may in any way accrue against said -
C.) City In corw�yuencv ofthe granti of permit.
APPLICANT UNDERST FP i COMPLY WITH ALL NON-POINT
SOUR .REcuLAT Issued by: - Date
;ci'�,t
para of elms ' r Date Re-root's
A OUS MATERIALS DISCLOSURE
Will the app leant fir future building oecupnnl Nnre or bundle hcamaki m.mnal Type of Roof
fied by rhe Cupenino Municipal Code.Chapter 9.12,and rhe Health and Safety
e.Section 25532(.)^
❑Yes o"° All roofs shall be inspected prior to any roofing material being installed.
Win theappliLmormmrebuildingnectp:mtaseequipmentordeviceswhich If a roof is installed without first obtaining an inspection, I agree to remove
huaxpi air contaminants as defined by the Bay Amu Air Quality Management
defall new materials for inspection. Applicant understands and will comply with
°Ye4 °Noall non-point source regulations.
1 have read rhe humnlous materials requirements under Chapter fi 95 of the
ifornia Health&Surety Code,Sections 25505,25533 and 25534.1 understand that
iffm building fall nor currently have a tenant,that it is my responsibility to unify the
culuw of the regal wh' be m prier us Issuance of it Certificate of
Our
nncy.
Signature of Applicant Date
Ovaer,rra I, ca Dam _ All roof coverings to be Class`B" or better
OFFICE
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