00040157 Crvu OF CUPERTINO .. PERMrr NO.
'� HI➢LINN,Lo
PING DIVISION PERMIT CONTRAC�T`Ok INF[ORIMATION:
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,fig LI// - C AI��Ta� v .� ' SANITARY NO, _I APPLICAION SUBMITTAL DAT
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ARCHTECrm-N INEER
BOLDING PERMIT INFO
a-,z
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z O,' LICPN$FD CONTRACTOR'S DECLARATION
I hereby
aRw that I w lle[med under provisions of Chapter 9(mmrrcxivg Job Description
�uEwto fol ion]Igp)ofDiv'ionJoflheBainessud Rvfessiom Cade,aM my littnse is
< in nett rorcesavdsLJ 'LFr,�[L A
iy{� uwlnt Z Lie.x g!'1
LL S LL y D01[
1 undeaNne my plass shall�has used aEpublic ltcoNs
r
i6 ° Licensed Prufeaiorw
n OWNER-BUILDER DECLARATION
t–z e 1 hereby aRw that 1 w exempt from the Contractors License law for the
EC follmving reason.(Section 703 1.5.Business seed Prat misar Cade:Any city or county
a which agnira a permit as construct,cher,improve, lenmbals err repair AnY mor—
Sq. FL Floor Area - Valuation
poor to its ismance,also squirts the applicant for such pemuuo file a signed statement
that he is licensed pursuant to the provisions Of the Contractors License law(Chapter 9
(commencingwithsecdon]dW)ofDivision3oftheBusinessardPmreuimsCoe)or PN Number ecu ane Type
fhat he is exempt therefrom W the basis for the allegro exemption.Any dation of ^ P Y YP
Section]031.5 by any applicant for a pemdt subjects the applicant to a civil permy of . —
ou moa then five luu Ac l dollars(S5110).
p I.aaawrworNemopenr.armrwployeawlthwagaathehwlernmpenwion. Required Inspections
will dathewmk,Wa: swcartiswiLicens Lawdoes
ofor We(Sex.]OCs.Busineu
and Profusion Code:The Contractor's License and w odw a such
era apply to as owner of
hpropertyis own who build,pr improve, such i and who dose tech t mk himselforthrough
his own employes,bedded r i such impos sold w w not mantled m Offered for
WO,If,however tits,building or improvement is sold within one ye or improve
for For-
1,
will have the wnfm of proving that he did not build or improve for purr-
pose usae.l. /
1, ownerofthe property.,Bexclusively Professions,
with linseedcanactors m
ronswa the project apply
]B,#,Buvnea and rrr v ss,Wi Code:)The Contractors Li-
whoc law dna rot apply loan owns of protons who wilds m impto th thereon.erd /
who La is for such projala with acanvactm(s)Iianacd punuam m theContractor's
0
License Law.
1 one cornet under Sm. .B R P C for this season Q
Owner Date
WORKER'$COMPENSATION DECLARATION
1 nertby.fhw unaR pmwty ser perjury one or Ne rmlawiag declaration:
have endwill Smut=37M
of the Lmyu Coale.for
WahabCompen-
workf as hick this
for by is uan 3]00 of N<Labor Calc,for the peRomrrce of Ne
work for which Nin pewit is issued,
❑1 have Lib will ore,fon Wands Compesf idne n Ineuww<.ss inquired by Section
My Wo IM Labor Code,for the,perfowance of the work for wy< I town 161xRued.
My Wo E ygPce certia and Policy n(p�(�{
Camee� n Policy O e a
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rTIrie section incident wcwPlead if IM pemul is mrone hurtNM ddlu,($100)
or las.l
1 ossify,that in the perfowance I&work for which Nie permit is issued,I shill
sol employ any promo,in an a m sly the Wurkeri Compete
#tion taws of Cahfo
Applicant
NOTICE TO AP . .If nifcate of Exemption,you should
income,subjM N ah Comp esti provisions of thc Labor Cade.you must
fonhwilh comply with such provision m ,permit shall be icenrd rtvaked.
CONSTRUCTION LENDING AGENCY
0 Ithereby a ..thn them,n itocaawction kiningagcncy for performmweof
tithe work for which Nie pcwil is Is,ued(Sec.3097,Co.C.)
LeM[b Name
(� 7 IaMcr's Addrtsn
{y) G 1 mtify that 1 have read thia application and ewe than the above mfomamu,is
S Cocom.I epee w comply with dl city and county mdwnce,and state laws alaung m
Z building comweum,amt hereby lathoou repreanutiva of this city to mam uPoa the
t..1 C above-memianed property for inspection purposes.
(z F„ (Wq,gra weave,indemnify and keep harmless to,City of Cupertino against
f„J lobilifiu,judgmenr,costs and expenses which may in my way aortia Mainn aid City
w W in mat"uem a of t mtieg this pewit.
[� h N•PLICADl'R, 'A' D WILT.COMPLY WITH ALL NON Yll
$i of It on
U ATERIALs DISCLOSURE
rOBnepplicmlor' thingOccupant store of".hazurd uuuxriJ Re-roots `
u defined by the Cupcnlno Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)P wv/ Type of Roof
❑Yrs lakNo
Will the applicant m/future wilding acupsm era equipment or device,which All roofs shall be inspected prior to an roofing material being
count hazardous air comwinents as de@ted by IN,Bay Asea Ah Q 0ity Management installed. If a roof is t stalled without first obtaining an inspection
R.0 I agree to re V a new materials for inspection. Applicant
❑Yea �'o gg
Iha seed the haaandou,mateoela rtyuiamenlaamde,Chapter 6.95 ofthe Cali- understa a l comply with all no Coin o ee regulations.
forma Health R Safety Cone,sections 25505,M533 eon 25534.I under that i Lha
wilding does n mly Unna,-Nal it is mY rc.[pomlbllhy m mel y t
of:tenor ter s' nen prim ler ofeCmifica
Si I/ o p ant Da
Ow t Da
of coverings to be Class"B"or better
OFFICE