00050094 CITY OF CUPERTINO ' " PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: nr-�Q as'OQ 9 J
BUILDINGADDRESS:
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OWNIinR'`S,NAME: on',`�I- C—XW NO CONTROL#
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ARCHITECT-NGINEER IRILDING PERNI1T INFO
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s. LICENSED CONTRACTOR'S DECLARATION Job Description
L O h= I Wmb ffirm Nat 1 am licensed under ions of Che 9(commenci
024.
t❑ y° and
Pro scar ug
F,v,tw with Secrecan00)ofDivision3 of Ne Business and Professiom Code.and my license is ,
in full forte and cRat.
m z z< License a.0 Lie. i C �'h
3�y Deu Convector
p.Lc O< ARCHITECTS DECLARATION
can a I undenrard mY Plans shall W uwd a public rereads
w i G O Llcemed Re
nenc m
c �5 OWNER-BUILDER DECLARATION
t 7< 1 hereby affirm that i am exempt from the Contractor's License Law for the
_€O following reason.(Section 7.3 I.S.Business and Pwe..iom Cede:Any city or worry
wmm""firm. crush toemsuuct.mitt,improve,demmBN.a rewir say.mssan S Ft. Floor Area Valuation
#dor w its issuance.mss sn Lies the applicant forsuch Mount he file.sigadmemmeq'
Nat he is IiansW punuanuo the provisions of the Convector.License law(Chapel9
(emourreing with Section700(yof Division 3 of the Businaa and protest....Code)or PN Number Occupancy Type
that he is eaIteration. nd Nxe
pt Item ae basis for Ne alleged amPtion.Any violation of
Section 7031.5 by any applicant fa.pared subjects the applicant to a civil pemlry ofC)
more Nen five hmW ldollm(15001. `
1,aszw l.fl pmany,ormyomdW=Swimwagow. irsolccmn nafim. Required Inspections
w 1l do Ne work,endlW structure tone inrendea aoRened fo...le(Sec.7 W Ilumnam
scrollsPrefessiom Code:TW Contractor's Liame law does not apply to an owner a
his a who builds or improve IWrton,and who des such wok himself a shough
mdfor
Aix own employerse provided!Out such improvements art ms intended a oReml for
sale.U,holdcr wi0rc Wildingman of om sssold withinaneyarafcompletion,Ne
r-W iltler will have Nc bonder of proving Net W did not Wild or improve for pur-
yyyf000�����,,,�of.ale.).
$I,u owner of Ne propenri an exclusively contracting wish lie<mnd con mmman in
�< eros d project apply
o an wneineu.nd ny,who bu Cade:)The Contractors V- /�
cense law dao not apply to an owner of mmemo who Wilds or improves Nemo,and
who contracts for such pojau witha contracmr(m licenrtd punuent m on,Canbectors
License law.
❑lam exam .B&PGT Nis
sorrel• Dat b O
WORKER'S COMPENSATION. TIO
IherabyaRrmunderpmaltyofscerjuryone a 011 owingdaclantimu:
Fl I have and will maintain a Cmifiate erectness m self-instre for Workera Compen-
sation,as provided for by Section 37W of the Labor Cade,for the performance of she
work for whim Nis permit is issued.
I have and will maintain Worker's Compensation Insurance.as required by Section
3700of Ne labor Code,for the performance of Ne work for which this permit is towed.
My Workers Compensation home me carrier and Polity number K:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE
(This section need net be comple¢d tithe permit in forone,hundred dollen($10()
or lea.)
1 candy that in she performance ofthe wak for whim this permit is ismcd.I shall
nm employ any person in any manner so as to bromem subject o the waken'Compcn-
smion Laws of Cabromin Data
Applicant -
NOTICE TO APPLICANT:IL after malting this Certificate of Exemption,you should
land.oub*1 he she Worker.Compensation provisions-fft Labe Code,you most
forthwith comply with such provisions or this permit shall be deemed raokal.
CONSTRUCTION LENDING AGENCY
QI hereby mBrm NU Vert ix•"men mm lending agency fent"pafumuna of
L the work for which this permit is is ued(Sec.3097.Co.C.)
F. Lenders Name
Lander,Address
1 unify Nat 1 have read Nia.pplicmim and mute Net the above in(onmtion is
as. zI.L I agree to comply with all city and county cadwnces mm some laws relating m
Z building cmmmcdon,and hereby smhaiss opresennewes of this city ro eons upon Be
V above-mentimsed property for impaction purpesea.
(We)agree to save,indemnify and kap hamdess the City of Cupertino against
Q Com) liahihoex,judgment,oomomd expenses whichmay in any way mcme ageing said City
} in consequence of the granting of this permit.
[— 6t APPLICANT UNDERSTANDS AND WILL COMPLY Vol H ALL NON FIRSTr
SOURCE.REGULATIONS. Y � as �J 9
Sigmtort of ApplicrnUConlracta Data s f �_
H RDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding recupent store a hande loo dome madol Re-roofs
u defimd by the Cupertino Municipal Cade.Chapter 9.12,and the Hemth and Safety Type of Roof
Coda.Sada.25532(07 yP
❑Yes C1 No
will she applicant or fawn Wilding occupant use equipmem a devices which All roofs shall be inspected prior to any roofing, material being
emit hawdous air contamlmms as defined by the Bay Ana AG Quality Management installed. If a roof is installed without first obtaining an inspection
District, I agree to remove all new materials for inspection. Applicant
❑Yes F1 No d
the read de,bmardaas ornmeme rtquirtmmes under Chapter695 of IW Cali Un erstands and will comply with all non point source regulations.
fame HeaIN&Safety Code.Sections 25505,25533 and 25534.1 understand that if the
building docs nes currently Aavc a enure,that itis my responsibility in notify the cecupent
of IW mlu temenu which must be mm pda m issuance of a Cenitiate a Occupancy.
Signature of Applicant Date
1)w..or authorizM agent Data
All roof coverings to be Class"B"or better
OFFICE