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00050125 (2) CITUDIN DIVISION NO CONTRACTOR INFORMATIONPERMIT NO, RI PERMIT 000501 OrMICA. pyP S: .Y/k �a I x r g//A1 1 t{k/VT)`yg//xVf SANITARY NO. APPLIC=T�N$UBwM D ©ATE 1 Y� �,.y RO Il I'J,//JIf I//L/IpYI�'rV�y`A Pi l 1 NIC CONTROLB r� �O ,Iw1% {'/✓1 �� ❑ BUI.DING PBRMIT INFO RCHITECT/ENGINEER 1 ° r -t�311 LICENSED CONTRACT'OR'S DECLARATION N o i= c Lha° :Timm by. 0 1 un liccvcd uMec prvvisions of Chrgcr 9(commerciog Job Description F y F w with Smtion]000)ofD'visio 3ofth yaincss Pmf l'rccmcis 't y 5� in full farce m f s... II`^/ /L` [t(/` , `/1 •{J—a—/Ya �}y� EU tiamc Clen a Q� ! x Dam Contncmr r °4ARCH r.,:T DEC v�y 1 understandmy plans shall M used u public records m E°° Liaemid Pmfeuiow OWNER-BUILDER DECLARATION n i N I hereby mmorn that 1 un exempt from the Conlract.e.License Law for Re E s e following msao.(Suction]031.5.Bovines,tad Profmaiam Cade:Any city or county w m which regyuines a permit to mnaarcL Wer.improve,demali,h,or repair my avuctae Sq. Ft. Floor Area a�R�tl,tk{Q pdormibi.manm,alsanquise,theapplicmtf...ch pumit m file.signed statement / Nu he is licemed pursuant to the Provisions of thc Commosers License taw(Clupa 9 ✓ l/ (commencing 7")of basis for o/the Belcoemdin.professions Cdc)a pNI anter Occupancy Type Wt io is 31.5 b anefrom and the burs for ubj Wcgd elilimo in Any violation of `.PD ( ( O Section 90]1.5 five anyapplicantdam for a permit subjects the app:imnt m a civil pemlry of Ot more than five hudrcd dollen fS500). 1,u owaa c,mil openy a mY ernployua with wage a mei(Sm 7(ompencomia Required Inspections will do thewons CdthmV Contcture rahiss notimenddor awdo,ore-apply to an,Bualuu W nory who Codon The C,n thence.and w law alas not apply as lf owner of gh propmy who build,or improves thsuch i ed are eat such work himself a through 7 7 7 3 Z `8 his own employees,provided Nat such impmvemid w tae not)made o oftcnd for uta ILmIdev wthe building or ren f mom is mrdwithin oneyurafcompletion,rhe redildtt will lose the burden of proving that M did eros Wild or improve for pa- nota u/Rale.). I,ut the of Neproperty,am Business and completing with licensed c,mnacst" - m.La d project(nee.]0a6,w.,of and rsy who bui d.or The Co therm,V- cert law scat nm apply 1,an uwmr of property who builds or imaavm Ncrmn,and .h.converescls for such projecu with a mnraetoe(,11venad punuent in Ntru Ne Cantor. Licence,Law. 01 un exempt under Sec. ,B9PCfor this rtuan Owner Data WORKER'S COMPENSATION DECLARATION C/ 1 hereby affirm under pemlty of perjury ore of the following containment: a� j I have and will mainWn a Cenificam of Conunt m self-insure for Workers Compcn. 4N�9 lion,or pr ivi&d for by Section 3700 of f Labor Cade,formic perf,mtance of the work for which this permit is issue. 1 have and will main orece ompenfl:on lamrame,m overused by Section J]00 of the laWrC .f of the woe for jIs Ni My Worker,Co u t me c and folic 11�/ Cartier: Policy No.: C TIFI OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section sed.bccompleted ifthe 1-11 is forone hundred dollen(SIM) or los.) I certify that in the performance of the work for which this permit is issued.:shall nor employ my person in my mammy to as to hecome subject,Ute Warken'Compere scion laws of calificrom Doc Applicant NOTICE TO APPLICANT:1f,vptt making this Cmificate of Exemption,you,Mold become subject in the Wark<rs Compensation PmviUmes of the Labor Code,you must forthwith comply with such pmvisiom or this prmtit shell be doomed invoked, CONSTRUCTION LENDING AGENCY O I ho eby offrm thin them is a commucdon lending agency for the performance of Z the work for which this permit is ivad(Sm.3097.Civ.C.) tiLender,Name > :.nears AddrtaR tor: I certify that I have mad this application and win wt Um rc.hove ofoution is 0. Qcorrect.I some to comply with aft city ad county ordinance.ad state laws.1Wng m Z holding construetion.and hereby autbodu rem<unatives,fibis city to mm,. mthe U O aWvcmemmud property for impron.purpose, Gar E., (Wm agree to ave,indemnify and keep harmless the City of Cupertino almost O U luhilitiro,jd,norm,cmc and expenses which may in any way accrue against mid City in mmer,ence of Ne goomng of this permit. APPLICANT UND17RSTAN US AN U WILL COMITY WI'I11 ALL NON-NII NT V Z SOURCE RIiGUL oIONS, /^ (/�.j/ �/) Signore of AppfcanUConmcta Date J1 �^ / r 3 HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future Wilding Mention store at handle haxudous memorial Re-roofs u define by tM Cupertino Municipal Cade.Channel 9.12,and the Health nal Safety Type of Roof Code.Section 25533(.)? yP ❑Yet ON. Will the applicant orfuwm building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being emit hummme Wc,ntamimna m defad by the Bry Ana AU cannot,Mmeg<ment installed. If a roof is Installed without first obtaining an inspection om,,t? I agree to remove all new materials for inspection. Applicant 0Yes F1 No Cori- understands and will comply with all non point source regulations. nreadtheha„rwmmatadaltm9aiemmaaderCapar695a/th fans Health&Safety Code.Simmons 25505,25533 and 25536.I undersand Nm if the building does rut currently have a amnL thin it is my nsponsdiliry in mtiry the occupant of don"s inme or which must be trot pdoto issuance of a Certificate of Cee-fency. Signature of Applicant Dale Ownerormalimisd.genu Daa All roof coverings to be Class"B"or better OFFICE