00040029 CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: _
(BIWUOILD.ItN'G"N ADDRCSS: A A�QL �Nf �, lY� Nex/ � ��q�N0Q
SANITARYNO. AP`IICATSSU
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ARCHIIITTEECC✓fENCINEER IULDLNG PERMIT INFO
Poo (f-MO&V- �44(,.
LICENSED CONTRACTOR'S DECLARATION
O =O I hereby aRrm that I w Ilchased mover xo,,.,iom of Chapter 9(commercial; Job Description
pKtLiJ with Section 9000)o(Divicion 3ofdo,Burins and Dofmi s ode.and my license is
=zeeO U in full force ad<Rttr. --�1/!/I, A� --jet I
u.ea. are.# Irk/_AYU 1/
a S LL 1 0' GOnracmr �1
1.,u O Q ARCH CTS DECLVIA ON
f uW y I s eh .s public meads
e a o� LIC sed Rf
610
,cm,M
DWNER-BUB.DER DECLARATION
MZ 1 reby arm deal I enI exempt from Ne Contractors LiceLaw w fm the '
'F O foil a (Savon'!OJ I.S.eusircss aha Tofcssiow Cab:My city err county
u.3 m which rtqun.a permit m construct.alter.improve,demolish,m cop.any s.nueue S hoer Area Valuation
prim Iona issuarce.also winner the epplicast for such pcmut m fileasighodmium sal
mut he is licensed p+nuant to the provisions of the Contractors License law(Chapter 9
(comm.ncingwith Section 7000)of Division3ofdm Busioessand Profusions Cadour peed Number ane T e
that he is exempt therefrom and the bears(m the alleged exemption.Any elation of P Y YP
Section 703 L5 by any applicant runs pemut subjects the applicant m s civil pen n,of i
not more than fm hundred dollars($500).
E]I,.own.ofulem
ppenm mge
y, yempleyes.with w. s we theirwlecompersona.n. Required Inspections
will do the work,end do,structure is not intended or offered fm We(Sec.7814.Busimss
aha Finesse ors Cade:The Contractor"License law does rut apply to an owner of
property wbo Wilds or imluova thereon,and who sista such wok himself or through
his own employees,provided that such improvements are not intended de offered for
We.If,however,that Wilding or improvement is shad worriment,year of completion•the
ciasim-lbuildsc will have the harden of proving that W did not Wild or improve fee pur-
pose of sale.).
1,in owner of the property,am exclusively contracting with licensed conductors to
conmue.the project(Sec.7W.Business and Pruft salons Cod,0 The Character's U-
cenulawdoes wenapply toInowner ofpmpenywW Wilds or improve theme,end
who conuaca for arch projects with acometww(s)licensed 1-1 to the Contractor s
Licence law.
I em ax.mpt trd.r Sec. .B&P C fm this wham
Owner Dat
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury am of the following declaration:
ko ❑Iheveand will meinuim.Cerifeam afcom..11.seR.inwmferwotkm:Compem
art,ss povided for by Sentmis 3700 or the Labor Cade,for the pedo.of the
for which this permit is issue.
I love and will common on Workers Compensatiha Inunrce,n requited by Section
3 ofthe LalsmCade,for thee performarucofdu wmkforwnich this cmi hili ed.
My Woh �rm 1`I c cam.and Policy
Carmen_ Y PalicY No.:
CERTIFICATE •EKEMPfION FROM WORKERS'
COMPENSATION INSURANCE
(This Rectin,need not becompletd ifthe permit is foromhudmd dollop HOW)
or las.)
1 certify that in the pedormnaof Ne work for which this permit is issued.I shall
nm employ any crion in any manner so as to become xubjm no the Wader Compen-
sation laws of California.Due
Applicant '
NOTICE TO APPLICANT:If,after making this Centre..of Exemptions,you should
become subject to this Workers Compensation provisions of the Labor Code,you It
forthwith comply with such pmvisiom or this permit shell he dared revoked.
CONSTRUCTION LENDING AGENCY
Q 0 I hereby affirm Hour them
iu conswedon lending gamy for the prfundanoe of
Z the work for which this permit is issued(Sec.3097,Civ.C.)
Isderx Name
[� 7 Leader's Address
W Q 1 certify Wt 1 have read rus application aha awe that the above information is
A. cornat.l Mom to comply with all city and county ordinances anal see laws muting to
.7 z building censtrvdon,and hereby audience repesenutivo of this city to enter upon the
V abov-ustru on.d pupenY for inspection puryases.
;U F.m (We)agree to save,indemnify and kap hamrleR the City of Cupdino.,.lost
C) V liabilities,judgments,caro and expenses which may in any way accme&gains,mid City
>. W in con"Ismon of the,cortin,of this permit.
V � APPLICANT UNDERSTANDS AND WILL COMPLY WITH All NONIbINTtZI / O
Nr'
.EREGIrIA ((—r
h�DD
r Signmre of AppliceHAZAR r � Deer
HAZARDOUS MATERIALS DISCLOSURE
will yteCuentor future Wilding e,Chapter
dnreor humoandtehanamhand Saor fety Re-roofs
u il.find by the Cupertino Municipal Code,Chupmr 9.12,end the Health and Safety
CodaSaliha23533(sl^ Type of Roof
❑Yes /Jo
Will dw.,[I ,or future Wilding ampnt us.'isipmem or devices which All roofs shall be inspected prior to any roofing material being
emit h.adome err canwnirwis q dcfindbyrre Bay Ara Au Qu iry Mwagen est installed. If a roof is installed without first obtaining an inspection
Yu g
District?District? t\�P[v/_' I a ree to remove all new materials for inspection. Applicant
❑
Ihave hand the nneardaa.material.owirenunaunder Chapter 6.95ofthcCah- understands and will comply with all non point source regulations.
limits Health&Safety Cods,Saxon 25505.25333 aha 25534.1 understand that if the
Wildingd.sndap mlyhevea rent,Wtit is my rtxponsibility to mtily oesupmt
f AE)Mwur
so
uwarce ofeCm ru
Signature of Applicant Date
Give cowl d agent
Data
All roof coverings to be Class`B"or better
OFFICE