01050152 CITY OF CUPERTINO
BUILDING DIVISION PER IT CONTRACTOR INFORMATION:
I{UILDINC AllDRliq'S: 1'13RM11'N).
/OWNER'S N E: (r ylk
APPLICATION SUI DATE
V DkL r/
1'iIONF.:�� / /�� / SANITARY NO. CONTROL NO.
n at ARCH] /I!NG 'l F. / - BUILDING PERMIT INFO
fu O O BLDG ELECT' PLUMB AtIiCH
Ew
a�� CI 1.I
F�FN7 LICENSED CONTRACTOR'S DECLARATION Job Description
pO 4 C 1 hereby rffirm Ihut I um Iieen,cJ under pnwi,ions nl CM1upter 9(a,mqu:ne;ng
F:t'� via, wool or Diy :+�n J,e H,r�ine.�-nl y.nex If`a"rte/I e -
n in full I'nrre v fl
V I,¢�< Licca
Date j.S� FINALED
w3
H< R 1h.ill bC1"S DI:CI.ARA n
E o,J 1 undcrewnd Iny Plans ehaJl be axed us public record.
E�— MAY
O 1 nnM
cat ua m O Licenmd Prom,cal I AY 3 1 2801
OWNER-Bl111.DER DECLARATION
I Iamby dfim,,hat I am ocnhm On he Contactor,Lncma Law tar the 1 U aJ E S' 20 1
t z S lullnwing reason.(Satan 9031 5,lh,eincxc and Pale,.......Cuda.AnY city or cuwny BUI I
V S C which ca pc n ., , IIimprove.demolish. n y unman DING
M
3 pm , , once I. req the f h permit file a s N imemcnt
that On,is licensedpursuant tthe provikkas of the c t ,r License la (Charter9 Sq. Ft. Floor Area •� 57 57 Vah�'
(commencing TI Section 70001 I Di i lith B , dI f tons Corti)
,),,bar act,csc npt,hcall at mal the bull From II g J til Any Irl a o, [
of Scaion 7031.5 by any applicant for a permit subjects the applicant uh a civil penalty
of not mom turn the hundred dollan(S5W). AP Number \ Occupancy Type
❑I.m owrcrnr the p.'npo.'.y Tray cavploycca with wngux m lhcir sole nalnticmallon. (/
will do,he work,,ad the,"sews is nm intended nr nR rd for .It (Sec orii,
Bnciners and Prom,ica,Code:The Comtanor,Liccnxe Law does not apply it,an Required Inspections
orur of pu),Arty Who build%or improves thereon,and who does such work himself
lhrough his own employees.provided @m such improvements are not intended or
offered far sada 11:however,the holding ain ln'ovmnen,is.sold wllhin one yen r TO
hmpininn,the ownermilder will have the burden of paving that he did nm hold nr
improve for""n of sated.
❑L m ow bur of the Property,am esulrctvely n ortatia,with licensed comractori w
sncnu I the pajce,(Sec.9044.Nasion,and Prom,l o m Can't 1'11e Comracvar'a
License Luw does not apply to an owner of nativity who builds or improves thereon.
and who contracts for such projects with a comtacmr(M licensed pursuant to-the
Convector's Licerac law.
❑Tu,it ca,un ,artful Scc. ,l{&PCliror,rcu,on
Owner Date
WORKER'S COMPENSATION DECLARATION
I hnehy alf,,I under pmn'y oI ticrjury n a afthe following declaration,: -
• O 1 have and will maintain a Certificate of Convent,o self-inwm for Worker's
Compensation, ac provided For by Scenum 3904 of the Lewr Code, for the
ap,rdmmancu or the work for which,hl,permit it issued.
wry have and will maintain Worker's Compensation Insurance,as requited by Section
T of the Inver Gds,for the perform cc
of the walk for which this peal it is
issued.My Wyf1,^kkccr',Pompcn ,Inwr J Poli
Carrier:{ —II� cy
CERTIFICATION OF EX— IT , Ohl ORKERS'
COMPENSATION INSURANCE
(Ihk"''Jon need lin,he"tat"mol i1'the pem,i,i,Ga one hundred filler.
Shia)or list.)
1 r nify that in the performance of the work for which this permit is issued.I
,Waal 11111 corkly ann any manner so us m
!in,Inen iIT, object ea,hc WalkerF
Cnmpercntion Laws TO chit'omlu.Uam
Applicant
NGTICii TO APPLICANT':If,afar making this Certificate of Exemption.you should
heconic subject ill the Wmkcrs Compensation provisions of the I,alxw Code,you num,
Q O tunhwilh snn,tily will ouch prowane.1 Thi,pct I'll''far be deemed rooked.
Fh CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a mmwnion lending agency for the performance
of the wed for which this penult is issued(See 3097.Civ.C)
Q Lcntfcr'.c Nunn
Q Z 1-ender'.Address
U Q 1 cenify that 1 hive mad this application and state that the above infomhmion is
oormct.I ugne,to comply wish of ci,y and coumy ortinar,cs and,tum hive relining
Q 6) n.building can,loull ,and hnehy main imrcpa•,ernlivcs ar this city it)enter upon
he aMrvcmenlimmA pro,it for in,,vtion Purfal".
t}„ L (We)agree in save,indemnify and keep haratthe City of Cupertino against
(n liabilities,judgments.costs and expanse%which may in any way accrue again,t laid
U Z Cay in come" •m' I,hc 6mmiI spermi,
APPLICANT L. GR$TANI. L COMPhY WITH ALT.NCTyy(11N'I'
' ' .1 -Io's. - /YC o Issued by: Dale
Signalmen Applinnnl ora actor — Date Re—roofs
1114DUIISMA'n?RIA1 'CLOSURE
win the appt,AZAR)0 wading C1.111 an handle I n w-dous mwed,d Type of Roof
as defined by the Cupertino Municipal Code.Chi 9. 2.and the Health and Safety
Cole.Section 25532(;)? -
oYc• ,c"o All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mare building occupant use cslipmen,or de%ax,which If a roof is installed without first obtaining an ihspection, I agree to remove
emit hvardous air eom uninam%as defined by the But,Arca Air Quality management
. Di„ria„ all new materials for inspection. Applicant understands and will comply with
❑Yee all non-point*source regulations.
I One read the hazudom maerialc requirements under Chapter 6.95 0l the
California Health Nr Safety fide,Section%2550125533 and 25534.1 understand that
If the but Id ing docs nn cuaenay have a mm n.Ohio is my respnnxibilhym and fy the
scup vat of In,rap 'conn„nhie act prior Ia Maurice of a Cutil mmuof
Occupancyncy' � 01 1 (''— 'G Signature of Applicant Date
o'”,limnrircdauto —eJ ossa All roof coverings to be Class "B"or better
OFFICE