00040086 CITY OF CUPERTINOPERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR:INFORIVIATION: oOg
I3 UII.DINGADDRFSS: p p T W
10-300 S�S EoI C' �V,� r F/��EN- ITA C'J(rO y�EMOD ELI N� SANrfARY NO. APPLICATION SUBMnTAL DATi
OW ER'S NAME: G2,0 Nr IOTN STa L�
eKr (R ➢ICKE2So .SA NJ30LEtCA 4SI IZ NIC evT
( i/oa 31 LI —1 g 9 Cp1ALT12ACT02.s Llc, 7roozz.( ❑
ARCIIITCCT/ENGINE[R LIU T-32 •1 3 c, rJ 13ULDING PERMIT INFG
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LICENSED CONn'RS DECLARATION
Z O rri- I hereby affirm Nat 1 unlicensed
under under provisions of Chapter,9(wmmeoivg Job Vescrl IIOn
wihSection t00(l)ofDivision3ofrheforiulaWProfevionsCode.andOn a.i, INSTALL GAILAGE IRltv(� (N L'�NDUI I
�x mm�rome.ndeBecr— 7loC2Z INSTALL EX 1 EtZICr?- LIC�ItTII-1Ca
< Llmnaec Ltc.«
tae`. °ea crolmpm` 1NSTA LL �L GFS :RECEPTACLE ON EX"['E21a!
O I understand my Plans she,]bye used as public records f O V b U TC CTS JN GAP-46
Orn i I fOSTALL a
Licwse l Prufessioal
u t)Sim, OWNER-BUILDER DECLARATION
I-Z i 1 hereby affirm thet 1 am exempt from she Contractors License law for the
-!EC following revon r5ection 703 I.S.Bunions and Profnaiovs Cade:MY City of county
OI
re
_ which failures a permit a comer icl.alts.improve.derolim,of minor my sutumm
3- prlorloits is[mn[e.also regaimn tne.pplicaut for such permit m fileasignd satcment Sq. FI. Floor Area -S Valuation Ov
Nat he in limrmd pawam m the provisions of the Comaetors Liwnaz law(Chaptec9
Iwmmcnca with
Section ruall of Division3 th Ne Bud exemption.
A.,avi Code)or
that io is exempt therefrom and tha burs for be cts me exemption.Any violation of +-y ^�p%(P��ij/N�1, b C nC�Ty p�
Section,703 than five
anyapplicantdot fora permit subjects Lha applicant to a Civil penalty of ✓G ( t/ U v v A✓a^�
wim
mon,Nen Eve hunrfted dollua($3(10).
I.ida,*wk.th ase ct misomi icy eioffe of r Ne(Sm.7m .Busadan. Required Inspections
will Bothewmk,ode: aeudumisrid.Lt.. I.awdutorulapply In an,Bmineu
and arty Whmu Code:TW Connector.License taw dos rut apply ro lf owner of
his O nY wad build,pr improve rhsuch improvements and who dons tech wah ided o f m thtouglh
bin own oweveremployees,the baovided r i such ers.is art ed intended m offered foe
tile.ILhew[se will
Wildingmimprovement isaddwithin oneild o,improve fee the
rf aer will have Nc Wrdw of proving Nat he did rat Wild m improve fm pm-
youof W<ne
❑I,u owner of ct property,am exclusivelynsand
protracting with:)n,a d eon rune. to
shad,des Or (Sec.Toad,Bmirhua and ny fessionswho lmi Codec The Conmcmla net �,J`
<enu Lew dos not apply to m owner of properly cola Wilda or improves Merton,rd
who coelaw.fm such proFca corm a wnlnetor(q licenved pursuant m the Convacmre r'1
Lianaz Law, g•J( /
l am exc .BKPG oris ration v
mer Doty v
.R'S COMPENSATION DECLARATION
1 rad nn under penalty ofperjury oro of the following deelaratiom:
have ad will maintain
L'M1Rcate of Consent In self-Insure liar WMkersCompen-
union,u provided for by Section W
37W of the l.ar Cock, performance for the performae of Or
work for which this permit is issued.
❑I have arta will maintain Wofkei s Comperratlon wutence.as regaird by Sardine
3700 of thc IaWr Code,for the pafformeoa of Ire work for which this Fermi,is iaxued.
My Workers Compensation Insurance comer and Policy number pee:
Camee Policy No.:
CERTIFICATE OF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section need out he completed if the permit is formrhehundred dollars(3100)
or leas.)
1 certify tlut in the pMormance of the wmk for which this permil is issued,l shall
trotrreemptor any persnntt i^ nnsnbKu9e`4ge4'io flu workers compere
maanamn awno
Applicant
NOTICEAP :If,after making Nis Canihcate of Exemption,you should
nor.a - to Ne Woders Compensation previsions of the labor Code,you must
forthwith comply wim such provisions or this permit shall W demand revoked.
CONSTRUC'nON LENDING AGENCY
I hereby elfin NU Nert is.connmdon lending agency fm the pednrmance of
Z Or work for which this
permit is issued(Sec.3097.Civ.C.)
F.t Lenders Name
�a > Land[rs Addeo
!zedz I certify that 1 have read the application and sane that Nma
Line above information is
1: const,l agree to cmnply with all city sedcounty intimaters And sate laws relining to
7 building emamctiro.and hereby authors tepreaeumivuof Nlapiny on enter upon the
ab.".nommi property for inspection purposes.
(We)vgraab,vve.indemnify and keep hamnless Ile City of Cupenine yeiat
O U Inhilidies,judgreema,cosy and asperse,which may in any way sc[rueagdnr ria City
�.r W in consequeoce of rue granting of this permit.
r 4 API'I.ICANTUNIIERSrANDS DWII.LC'OMI'I.YWI'FHA1.I.NON.l(INT
Z SITU 'IND'ILAI'fON4.
g 211-1=1L
Ilr,m,Convador Dam S
HAZARDOUS MATERIALS DISCLOSURE
con appliantorfumurtWildingowpentsmreorhWleharadousrarctid Re-roofs
as defined by the Cupertirm Munici dc.Chapter 9.12,and the Hcelm ud Safety T e of Roof
Cohn,Section 25532(,)7 / yP
Dyes ❑
vWinw
Will the applicator or future Wilding eccupmt use equipmem or&vier,which All roofs shall be inspected prior to any roofing material being
it hda air contaminants as drfd mby Ne Bay Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
agvee to remove al ew materials for inspection. Applicant
❑Yes
I have mad the haatdwa e materials mr,limnenunder Chapter 6.95 of the Cali Bnd t s comply with all non point source relations.
renis Healm&safety Code.sections 23X15.25533 and 25334.1 uddsund that it the '�// �f,
I ildingdoneoletreen0yheveeten that it is my responibility a nmify the arupsut
arthe wM _7 m issuance
ar.c trot apuyarn.
V Sig t4,Applicant Date
ow ,gem oar
All roof coverings to be Class"B"or better
OFFICE