00030048CITY OF CUPESION - r N > ° * r - PEr+M g�
nug.ot rc urvptston �I PERMIT CONT RA/nCTQR IN)jFOpRNIAT{1�0 1:;a, 066
TNG ADDRESS ����V ���� �K �LLI �C / ✓ f /e.
,f /� /J SANITARY NO. APPLICATION SUBMITTAL DATE
O $R'
NAMvn /1 /// nm&l // ' NIC CONTROL#
(U)752-9102 y/(fi�gVrUd/l , Cf1 9ys%S /�22
ARCHITECTIENGINEER(�/D ��/�• %I/r� BULDINGPERMITINI'd-,
O¢Z J 26
uoo
H u
LICENSED CONIRACfOR'S DECLARATION
1 harcby aRnn Nat I am licensed under provisions of Chapter 9 (commencing Job Description
wiNS.hod7(00)cufDivi'on3 f Busime and Pmtt,viaw Cade -
my �PPp��� 9� qc,/IGS uroferfo`��
Cx�Q Li Nllfmceand ellen.
Lime.9�71 C N
3 u. y Date C'
F te o Q ARCHITECTS
DDELLECLARATION
1 undenurd my pans shall W used u public meads
m z Licensed Profealnwl
u OWNER-BUILDER DECLARATION
F- z 1 hereby aRml has. I am exempt from He Contractors License Law for the
E = o following reason. (Secriw 703 L5, Boniness and Pmrassions Code: Any city or county
3 a which rryuires a Parma m cwuwn, Nle,. improve, demolish. m rapid, any incomec. Sq. Ft. Floor Area V ration
prim to its isswme. also onFires He app&am fineoeh Permitm file • si'md eutcmem
ND
Ne, he is licensed Portion to the Provisions of Na nse Contractors Licetaw ICMper 9
(c..cine wind Section 70W)of Division of this, Business and Pofessioru Code)m APN Number Occupancy Type
wt be is wens,; thercfmo w dlc basis t He alleged exemption. Any violation err P Y YP
Sation 7031.3 by any apPOwal fora pctmitsubjects IN applicant to • civil perWry of U
more Nen Bvc hunsdncd d.11an 13500).
❑ I, asOwn«Or Nepnapcnr.mmremploy«.wiHw.gaaHei,colaaompewtiw. Required Inspections
will Prfewoh. ands: heCortistrotamendedm awdoforata(Ser.otra owner
and urs, wh ow Code: The Cwtracrora. and who
Isco soca Iwl appy m If owoer d
propmY who Wilda m improves Hereon, and wW doea such woe himself orthoughf
ais own outv"'«a, Provided dm made muni I. sold
are not intended m offend for
auvrer-huwcver.IW Wildingmin of proem ithalhe within yworeompletsan,H.
Wilder will have IW human of pmvine Net W did trot build or import, for pm
time of talc.).
m L a mwncr of the Sm ert,7(au e. cadusi and mnracting wind :) The nersioon - O
caus La Neprojectply to
owner
of adry who
Ni Code:)The Conraoon. nd Q
who contracts
Isco does nm apply to la with
a of Prnpmy once W ilde n impose thereon. and
w cense Law far such Poja. wadi a conrsanoAal licensed panwnt m IW Convacorn
01 anlaw.
1 am exempt unser Sm. . B A P C for His ammo
Owner Dne
wORKER'S COMPENSATION DECLARATION
1 hereby aflirtn under pantry of perjury one of the following d«Iasitiom:
1 have and will main.-a Cenifiwtaof Coossm to self-immu fm Worker's Compo
sation, as Provided for by Section 37W of the UaWf Code, for the Performance of the
war m which His permit is issued.
[gel have and will maintain Wmkars Compensation Imureace. a ouluitd by Section
3700 of Ne Labor Code, for IN punfwmmce cifthe work for which this permit is mud,
My Wodta;�n sppegsa/sanee eerier and yolicY/umhr y�Qno/O/ fi
Carrier://ii ///1 // Pal ic No.: ��.0 sC cl
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sarin. rem.m be complaed ifthe proal in format, hundred dollen 151(0)
or less.)
1 mudy Nat in thepetormance of He work for which this Permit is issued, l shell
not employ any Pro. in any mmner ao as o Wrnme subject to Nc worlma Compn-
,mimn Lawsol'Culifomin Date
Applicant
NOTICE TO APPLICANT IL after making Hie Certificate of ExemPlion, you should
become subject to Ne Woeers Compnution provisions of the LaWr Coate. you must
fmthwiH comply wind such provision. or His .it shall W domed invoked.
CONSTRUCTION LENDING AGENCY
I hemby uRrm thin them i... Ngen
nslruon lending agency for 'be pRmmance of
Z ti the work for
which this
permit is issued (Ser. 3097, Civ. C.)
E. LeMers Name
4a 7 Lenders Admaa
W 1 certify Nm I have red this apploatim and them that be above information is
0. corseet.1 ague to comply with, all city and county mdialum a and nu¢ laws relavas o
O building concoction, and hereby amlmmo on H
dre mpeeautivei of this city enter alum
U
above-mentioned ptupeny for inspection purpnsa.
[err F•' (We) agr« to save, indemnify and kccP Initial., the City of Culsem. against
C.7 liabiliuca,jndgmema
man. and..pante. which may in any way amou, against said City
;a. W in consecra me of the ting of Nis'emn.
F APPLICANT UNUF . ANDS AND WILL COMVIY WII'N ALL NON-Ib Nf
SOURCE BF,GU
Sig..ofA,hc m DOUw Date /��a0
S MATERIALS DISCLOSURE
Will this, applicator forum Wilding mcupmt,am or handh hassrdoua mamsal W_9K0fS
as defined by the Cupertino Mum, I Code. Chapter 91, and the Heald, ad Safely
Cock. Section 25532W7 Type of Roof
❑ Ya m
N'tli the applicant or future Wilding occupant use a9vipment of devicna which All roofs shall be inspected prior to any roofing material being
-Akmit hazardous an cmntamiwnuaa defired by dee Bay Arca An Qutiry Mmagcsncnt installed. If a roof is Installed without first obtaining an inspection
H"'
❑Ye a 0 I a ret, to re ore all new materials for inspection. Applicant
nr
Iha.e.dtheInedenam.rnt
,frepitenm.under Chaptr695ofthe Cali. un erstands find will ply with all non point source regulations.
ramie Health B Sony Code. ma. 25505, us33 sed 25534.1 anden.nd ton if do �% /}�(
Wilding does not currently ha eatewnt. Tho is naprosamilryomtifyrheme.,ait 3 ` (�C/ll
err Nc re9airanen, w7 n b iron.« errs Cnufi u Otto
Signature of A nl Date
Ow«rmauswnzd erg st ate
All roof coverings to be Class "B" or better
OFFICE