00030187 CITY OF CUPERTINO ^' PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: D� 3 Z) )
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BUILUINDGADDRESS: /` �' pluu' TNG .
`�/JV� SANITARY NO. APPLICATION SUBMrITAL DAT
D ia�s Pert-Awe
NIC CONTROLN
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AI/tC�IIII�IaiC,I�'/EN�G�IN�EER�� I �� fy —a� BULUING I'ERMI'1'INFO
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LICENSED CONTRACTOR'S DECLARATION
O" Inmrb aRrm Nu1em livered uada f 9(commercio Job Description
Y Pmvid os o Chrpa g �N ` / -7
oy_� withSecti 7")aMvision3ofde Bust=sW Code Wmyli«mcis
in full force rad effect. 17,
paU
Liccnss Conti
w 3 a H Dvw Conwcwr
RCHrI'ECrS DELLA ATION
�v�2SyydcQAW2ZTJ4llMuud es publi<rccads
adoc adf i
^_ I care OWNER-fl DECLARATION
I hereby aRml that I me exempt from Ne Contsacwh License,taw for the '
s D
to
awing reason.(Section 7031.5.Buaile r W Professions Cede:Any city or crunty
which requires a permit to nmwcl,titer,improve,dcmoliN,to rtptir any awctme S Ft. FI or Area / Valu. i n
itmn
Friar to its an ,dm"W ries the applicant f«such permit w file.sigied statement
IMI he is licensed p rnamt to the provisions of the Conta«ota License Gw(Clogs 9
(commencing with Sections 70W)of Division 3 ofde Busircu and professions Code)an pN um r u ane Type
dal he is exempt thacfwm W doe basis f«the dkgW exemption.Any s'ialation of � P Y YP
Section 7031.5 by any applicant far a permit mbjccu the tr1licanno a civil peaWry of �
pt more them five hundred dollma($500).
I,aanwnerofd propeny,«myemplayeeawimwage wu irsolccmnp[matian. Required Inspections
will doefewank.Cot: he Ceti isnm,netlensre offeredfor Wt($a.7004,Buaimss
and property
whom Code:The Co r ducts'a License do dao not apply to lf etre«of
progeny mr builds or improver duction,i and who does such work deed or O through
his own employees,proddnd Nil such improvements ase not intended m offed for
We.If.howevcn the Molding or improvement issoldh within elle yerrof completion,the
owmnbuilder will have the burden of proving Net he did not Mild an improve for per-
1,
unI, u ower ofthepmpcn�7tu ran exclusively conuacting with Leased Contractor.
to
ce.uct Ne Project apply
o as Bus,of and Professions Cndcn The.therlola nd
nmc law d«a not apply w an Owncf Or ancon( who sed fa m ind rte do,d<reon,and 'Ere/
wMnmhmts f«ouch pmjau with a contrmlorral licensed pmaant w de Cantramta
❑I am ezcmp order Ser. .B 6:P C f«Nis rtnon
Owner Dne Q
WORKER'S COMPENSATION DECLARATION
pena
I provided
Se tion 3 M of
cam arriveode,followingftefie daratiom: v
❑I have and will meinuin aCertificate of COmenuo ul6iname for Worker's Compen.
salon,a providN for mi Section 3700 of IM Labor Cade,for the perfolmenn of the
w k havar e
and this perrturna is issued
1 nOVC Nd will malnlaln Wm'L/s GOmpen{Bllml 106arBllC[.0s KQYYCd by$Slpn
3 of the labor Cade.fm tad perfarmarRe of the wwk fpm wbhicWh pthgis permilu issued.
My We, Khyfi 'o surexecslai PoI No.
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Glrieci...{`..spa
CERTIFICATE OF COMPENSATION
I NIRON WORKERS'
COMPENSATION ae part NCE
retia secdm.mm ma betmavl[d irNe prams is mronnunmad ddlan(slao)
or less.)
Icenify Wtint Nrformann ftheworkfmwhich Iia permit isissued,I andl
of employ any person men m u to Workm'Compete.
on
Asspfilcanw
n
NOTICE A PLIC T:IL of r ma4'ng thio Certificae of Evcmpion,you should
became s bj to Ne Workres Compensation previsions of floc Lubor Cade,you..it
fnnhwiNc reply with such provision,onhis permit shall be demand revNW.
CONSTRUCTION UMNG AGENCY
z 2 Ol hereby a,fin t dw men is•conslmcdan leading agency forthe performance a
the work f«which thu perdl is issued(Sec.3097,Civ.C.)
I nate,Name
(Y >_ Undels Address
I certify that 1 have rad dux application W nae that tad above information is
0. conal.I agree w comply with dl city W county andivncea W'am Rove relating to
Z building conswetion.and M1meby amhmiu rnamentatives of this city to enter upon the
U O a nse.surnoned property for iupation pentmeas
ks H (We)agree to save,indemnify and keep hanalas the City of Cupertino against
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liabilities.judgments,costa and expenses which may in my way accrue against said City
^ys Lal In consequence of dere granting of this pemlil.
'pa � APPLICANT UNDERSTANDS AN I)WI LL COMPLY WI tH ALT.NON-4)I N'1,
V Z SOURCE REGUTATIONS.
ti Signature of A,li.VC-..Clm rare
HATARDOUS MATERIALS DISCLOSURE
Will tMapplican,m far.Wddiag«tuyant atnrt«Mndle hculand u.a a Re-r0 fS
ss defined by IM Cupertino Municipal Codc,Chapter 9.12,W th<Hadth W Safety Type Of Root
Cade.Section 25532Uy1 yP
❑Yes Bk NO
Will the applicant or future building mcupent use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit Mwam,air conumiarms es defined by the Bay Arm AU Quality Management installed. If a roof is Installed without first obtaining an inspection
Ulsairtl
E]Yet [d No
1 / I a ree to remove all new materials for inspection. Applicant
Ihasadthe hanardan1/NNsneswtidrmgaimmentaunder Cha «695 of NeGli_ understands and will comply with all non point source regulations.
forms Health At Safety Code.Sections 25505,35533 and 2 Oof4 I understand Nm if the
Molding d«s and curmllly hipetisconot.t.a is mY respomibilitywn«ifytheoccuprl
of the t Aich be ren an to to issuaaee ofn Cmifi m
Signature of Applicant Date
t"),sc
reu sad agent Dam
All roof coverings to be Class"B"or better
OFFICE