00030147 (2) CITY OF CUPERTINO i PERMITNo
BUILDING DIVISION PERMIT CONTRACTOR DNiFOf +MA�TIOg 000 3 0147
BUILDINGADDRE$ C&5) V ?? 7-
153� a�U �/VI/� /V,/Vr//��(i'/• UCJ� �atll. SANITARY NO APPLI q�SUB�IQDATE
A/t," N/C 3/CONTROLL#
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ARCHITECT/ENGINEER ^/Q ,x�ra• is i1/f sir A-Lf)IN 'Cf?ItM111f MP0
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LICENSED CONTRACTOR'S DECLARATION
p Y=O 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commenting Job DBSCI'I tion
o d w withScclion]OOB)oBand
_ wilmar Pmfamiom M Code.amy liana is 50 9� /all
I ay in full fortt and.Beet. A
m atony Cl uex
Date cmwcmr
O< ARCHITECT'S DECLARATION
1 understand my plane shall W used as public retards
a�CC Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby e@rm that 1 em exempt from she Contractors License Law for the
sF o following tiros.(SM M]031.5.Busirces and Rvfeauom Cede:Any city ltr munty
w—,e which ke issuance,
sn permit so cmmwm,eller,improve,h permit
so
fie a sig any statement
a a_ S FL Floor Area V•�1 a Io
pat heI. iensarl Ia orequires the applicant for mchmema.Lt... aw(Cned et<mem LI'
(,mar areoraneed Samctmtheproviskh 3theCmvecmre License law(C ono)as / U(✓'
(co he is ixem iNgeefim.and
Divisionr delve Buxt..ainess apd...A voitoo)of APN Number Occupancy Type
Section is exempt thmefrom.nd tan b.eia Per me an<ged Ticar to Any it Penalty of // . P Y YP
Seaton ID313 five
any applicant for a Permit sobjecm she epplicanno a civil penmry of //J •/ ,9&
wia mmv than five XaN dollen(11504). xtYY v
Lasowucrofthepese ct mit nmiployeeew off. fws Wi(Sm,7 mperusimas Required Inspections
will dothework,ands: he Comment's
om isnot inrmdedmawco Imrolapply to an,ownera
and Prosody
wbone Code:The C es them m Lienee lea does rat apply m lf mvntt gh
progeny who build,pr improves such improvements and who dna such work ided as m through
hon own employees,provided r i wch entIssoldwithin
arc nm iyear of
m ofrered for
ala 1f,however,will haveding
ban en of proving
t mid,did r one Wild
rf completion,the
ownerW ilder will harc thC WAcn of proving Ihas he did m,Wild a imparc for pw-
pose of vele.).
❑I,m rnanr of she property,em exclu,IvelY convmting whh l Tbaad rtmemma m
coed a she project(Sec.]BCC,weer of ltd Pr,who Ins Codr i Thevei da ors nd
cense Law doe,not apply e ts owner of pmpttty who build.or anttavm Warton.and
who .Lams for such projecta with a conusnogs)licensed pursuant the Conlnmorn /
Lianm hew. u
❑lam Cxemq under Sox. ,BkPCfm alis wan O
Owner Data '
WORKER'S COMPENSATION DECLARATION
I hereby affirm..do pmah,of perjuryone of the following daclamrims,
I have and will maintain a C<nlfi,me.fConem,ro self-insure rot Wmkee,Compm-
mtion.ex provided fa by Section J]00 of Ne Labor Cade,fa the peefmmana of We ,
work f which this permit is issued.
rave and will maintain Work es Compensation Insurance,as required by Section
My m We orkeWe Labor Code,!a trc peAormance ceof d work fyoyrpwbhi�chyWis pmnis u imaged.
My We ju{ygy,<gsAi'ryp�pyrgnce rci Policy No.YGfY/1.K.Li O/CJ
(_ff
CERTIFICATE OF EXEMPTION FROM WORKERS '
COMPENSATION INSURANCE
(This sector ma i nm W completed dWe panic is Burma hundred dollars($100)
or len.)
I cenify rise,in she Performance of We work for which this paned,is issued,l that
not employ any peraon in any menntt m as to become wbjem to the Workan'Compm- -
swim Laws of Calif..",Data
Applicant r
NOTICE TO APPLICANT:If,after making this Cenificate of Exemptim,you Ywuld
Inatome subject to doe Worker.Compensation provisions of the Lehr Coda,you must
forthwith comply wiW such pm oxi..or this pnmit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
z O IWrtb licathisho Wele is a conatrmton lerdingagency for the perfoomme of _
z Le work for which This pemd is issued ISa.3097,Civ.C) _
[.a .w Lenders Name
Lenders Address '
fz] 0 1 anify That 1 have read all
y and
and cute that OIC above Information In -
L care...I agrte to comply with ell city era county malas e,and cum laws rtlating e
r7 z bInvve-gconsuvcaroand here by amWriurposes. mivm of.hiscity menter upon the
C.) above-mcmianed propene for inspection purposes.
(We).gra to neve,indemnify std kap
IF:.].) V eanb,.mrsand expmus
an We City
of Cupetno against
not,I.any weYecmeaansr said City
>a a' in
consquenceof We of his permit.
APPLICANT UNDERSTANDS AND W111.COMPLY WITH ALL NO DINT
tZI
SOURCEREGULTION. �
J
5� �
Signature alAppl � Q
DaRUS ase
HA Windo.,licam r/
ding occupant store or handle hazardous material Re-roily s
as defined by the CuPCrdm Municipal Code.Chapter 9.12,end,he Health and Safety
Cale,Section 25532(.)] / Type of Roof '
El Y. td No _
Will the applicant or future Wilding meopow use equipment or devices which All roofs shall be inspected prior to any roofing material being
erm heealloes air co eminame as defined by the Bay Mee Air Quality Management installed. If a roof is installed without first obtaining an inspection
°'`"
Yea I agree to remove all new materials for inspection. Applicant
❑ d
I have l<,d dR ha,.rdm,rmteriala ass immems Peder L,Lpmr695 nIda G.li-
understands and will comply with all non point source regulations.
ami,Health @ Safety Code.Secdau 25505,25533 and 25534.1 understand that if the 5)211,
� Zl QQ
Wildingdamnmcumnllyh..".ens,WmitismymsponsibilitymnmifysMaccu I
of We tryuimmeme uR be me[pnitr w issuance of a Cmifimte ofq cu�9c
-R/�� Q Signature of Ap icant Date
unma mut 'zed age I 07 Doti
roof to be Class"B"or better
OFFICE