00030012 CITY OF CUPERTINO PERMITNO.
nun.mNc DIVISION PERMIT CONTRACTOR INFORMATION: oQQ 3 OO(
BUILDING R[SS: 'L /� N
L• // rI/t/// fflI,A�6i O2` / Mr. SANITARY NO APPLIC 41 5BM�ITT/AL DATI
O 9 ME: �'/� !� /�//p/// G NIC CONTROLN
Ir 7005' /(/ (�/ler �A959s °
'NITF,Cr/IiNGINEER HULOINC PERMIT INFO
�E
F�F y LICENSED CONTRACTOR'S DECLARATION
Z O v'i I hereby affirm that I am licensed under 'ons of Chapter 9(mmmeain Job Description
O,_O y. Provisions P 8 P
a=t� wiNSauon]000)af(Tvixion3ofdle BusinasaM Pofmsiom Coli,and sy littnxei
mfullfomeandidr.. L/f
Q Wceve Lic.N /�
5<3OWU
LL H Da.e Conuamr pot"7`l
F LL O Q ARCNTTBC7PS DECLARATION •/! C
f 1 udeaued my plant shall a used u wblic recpnds
«`oaf
a a Oe 0' Licensed Protessiorol
OWNER-BUH.DEK DECLARATION
C 2< 1 bemby affirm Nat I sm esempl from the Conuactofs License law for de
D following as»n.(Section]0)I.S.Business and Profeviom Cuda:Any city ne only
�« which recliner a Permit to construct,slier,impmve,demolish,or,repair any s.uutua
3 prior to its issuance.also aquias the applicant for such Permit to file a signed statement Sq. Ft. Floor Area Valuation
Nat he is licensed purmom to me pmviximu of the Com aclols licme law(ClhaPla 9 D• UO
(Commencing wish Sudor 9000)ofDivision 3 orthe BYxlne4 and Protection Code)« ApN Number Occupancy Type
Net he is exempt Nmefrom and the basis for On alleged exemoioa Any victim.a e O// P Y YP
Section 703 L5 by any applicant for a permit mbiuta the applicant to a Civil Penalty of
not rtoa Nen five aundad MI1.(35001.
❑tax sonar Prins proputy,«my employ«.wish w.gau theirmla m«mpmm.don. Required Inspections
will do Nm work,and theawcma is not intended m oRcad for selelSu.]614.Huaia.
and professions Codc:The Contnuori License law does ant apply to an owner of
property who builds«improves thereon.and wed does such work himself er through
his own employees,provided dod such impmammms ere an intended«oRead for
sada,If,however,Ose Wilding Or improroam'is slid within one yeerofcompletion,de
own«-Wilder will have the When fproving Nes M1e did not build or improve for wr. /
Poe of aslant. (�(Y_'`t�//L�►—`g
L ss awae or de property,.R exclusively conuecung with Hemmed mora ess m
n.U she proien apply
o a x,Roviowner
ane Profesdnns Code:)The Conmcoh nd
csa doas apply.oan owner of property wed Wilda or impruvex thereon.and
whoconuacts r«mch Pmiau wish.cunmcmrta)Reared punuent m Ne Conurtorx .
Uc
Owner law. //W/
Cl son exempt under Sec. .Bh PC f«Nis won /
Owner Dam 6/
WORKER'S COMPENSATION DECLARATION {�
1hereby altaunder Penalty n,ofjoryoreorda fnllm insfor decWwke?s Co V O
Ihsve ad will forbynaoon 37 te of ftILmonsd6inmaforWmtrracoman-
ation,uprovided for mi Section 3]00 of Ne Labor Code,f«the performance of the
«which Nix pethol is issued.
wort have and will CMC,
aperWorries Compensation Wurr which
h his Per by Section
my ofshe Labor Cala for the pmrtormance of the wart for whicM1 Nis permit is inured.
My Work<rsC in
QfJ✓ 5zannuand Policynu
Camcn:� LPolicy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ecoun rad no.be comVleme irlhe permit is foronahuMMdollen($100)
«I..1
I certify tan in din performarceaf lm work for which this pmmil is issued,l shall
not employ any person in any roamer as as to hccune mbiCet to Ne Workmna Compete
section laws of California.Dam
Applicant
NOTICE)O APPLICANT:If,after making this Certificate of Eaemppion.you should '
become subju.on Ne Workers Compensation provisions of she Labor Code,you must
foMwith comply wish such provisions or this artn;t alis[]W domed avoked. -
CONSTON LENDING AGENCY
Q RUCTII hereby dfrm thin Nem is a construction lending apply for led tertomuoce of
Z da work for which this permit is imued IS,,.3091,Civ,Q
Leaders Name
> tenders Addrecx
Is71 certify don 1 have read Nis application std dust at Ne above infomahon is
04 ACo.,.I agree,m comply with all city and county ordinances and state laws.1.1-9 to
Z Wildingcasswcuon,and M1cabywlhoine reprcaessamICsor Nis City m mill upon the
U 0 s r,ormukud property,for inspection puryoas.
fs F (We)agree m viva,indemnify end kelp harmless the City of Cupertino-0.1 '
U Hmili&.s,judgments,cos.and espenas which may in my way.c.a.gairstsaid City
^�. w in c."ueae of the granting a shix peit.
i � fA
APPLICANTUNDERSNDSAND It I.I.COMPI.YWIIPO
'HAUNONINT
U Z SOURCERF.GUL IONS.
2 ?d5 077 � is 7 f
Sigw naofApplim tpe c ale J59 A-/Zb•k• U C.�.•
HA OUS MATERIALS DISCLOSURE
Will ceapFrA
lican Room building Occupant atom of handle haaandous material Re-roots
as defined by the Cupnsino Manm I Cade,Chapter 9.12,and Ne HaW and Safety T e of Roof
Code,Seldom 25532(a)] / YP
0Y. Na
Will Ne applicant or future Wilding uculam use equipment or devices which All roofs shall be inspected prior to any roofing material being
mit h.vNana ah eonuminenu u defired by the Bay Asa AR Quality Management installed. If a roof is Installed without first obtaining an inspection
0,or, I agree to remove all new materials for inspection. Applicant
Yes
li.etidN h.,�nam aaagniam and rL.p 695nfN Ga - understands and will comply with all non point source regulations.
fomu Health&safety Cale,Sections 25505,15533 and 23530 1 understand Net if Ne n
M1uilding d«x n«ca cn0y have o mini.,0yy0 .is is my asµmaibility m nosily the occupant
of Ne aquiamen imh must he �or m women of a Cenificea f o 9 a
Signature of Appli • / Date
Owner or auNonze t Date
All roof coverings to be Class`Be'or better
OFFICE