00040048 .CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTORIgINFOk RIM/ATIOO N': o o O`i, f 0 O/-/ 9 v
BUILINGADDRIESS: _ OSE�0 •� SANITARYNOAPPLICAT E
OWNER'S NAME: \ a2o31 .rL1,rvQ ,l.. _. NIC- CNTL1 RpLp
HO J
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tCHITECr/E GINEERr C��tg- r 4 •`O c�"'J [�G�( 0111.DI,G I;ERMI INF,p
0-an , Fin .e �' ' k . ✓. {J
Goa
FFes'^ LICENSEDCONIRACnder DECLARATION
0.0 0 , thereby Cfim Neto 3licensedideapwviaionsof Chapter myli Rndng f Job Description •,
with sectirn9aoo)mrpiviak,n3rrthe Bmaitmaa.na mxas,irnsedb.at,a mr fianse is �' -
�. Q in full rote aM<RecL
y O w V Linn¢ tic.N17:2f .
O G ARC CTS DECLARATION
1 senders Nims ah used as public semNe - -
d ucered feu, nil -
vS OWNER-BUMDER DECLARATION ,
Y i hereby affirm Net I am exempt from the Contraaoet License Law for Ne
Ofollowing recon.(Section 7031.5,Business ad Pmfeuiom Code:Any city or county :.
which rtquiree a,pemit m cmtswcL dter,impmvc,dennliN,or rtpa'u any amx:lweO
b primmits iasuence,dw rtquim Ne yplicwtro ouch penCl Nfileadgned sutemeet 3q.FI. Floor Area _ V U n
rlutheislicemedpmnuanuo Nepmvisionsof Ne Comr &s LicmwUw(Clupter9 A
(commencing with Sanlon 90007 of Division3of NeBminna sed lhrfueionsCde7o r� 1 ,U� Occu anC
Nat he is exempt therefrom and Ore basis for the alleged eump0on,Any violation N N r
of f"(T4P l p y Type
Section 70313 by any applicant for a permit subjects the applicant to a civil penalty of
nm cure Nen five hundred dollars DEMO).
❑I.asmvnamrOumnperty.ecmremployne.wiNwrgas..Neirwle.nmpen.,dan. Required Ins?,,ons
will do Ne work,and the snudurc is not imem eduroRer l fm We(Sm 9044,Entire. _
and Profasdon,Code:The Cismamor's License Law docs not apply to.owner of _
property who build,or imp ovcs Nere.n,sed who dras such work himself m through '
his own employ«.,provided that such improve..ere am intended a oRcred for
sa!e.If.however,Ox uni ingot improvement is sold within one onecufcomplid..,the
cr-Wilda will have the burden of pmving that he did not build or improve for per,
pose of sale.).
I,On owmr of the property,em exclusively contracting with licensed conurtrors to
onauuct the project(Sec.9004,Business and Professions Code:)The Contractor's V.
me.law doer m,apply,o as owcer of property who build,ar i.,..thereon,atd f/
t who contacts for such projects;withamntrwmr(a)Inertial Norman,to the Contractors '' O
License law..
❑'l mon exempt under Sm. ,B k P C for this reewn "
Owner Date -
WORKER'SCOMPENSATIONDECL. TION
' 1 hmeby aRrm under penaty ofperlury arse of Ik followin8 declentiom:
a IhaveandwillmainWnaCenificamof ConsenHbulf.insumfor Worker',Compen-
tion,as providd(or by Sse on 3M of the labor Code,for the performance of the
As for which this pem0t is issued. '
I have ad will maintain Workers Compensation Insurance,as required by Section
00of the Lab rCade,/or Ne performerue of the wok for which Nis Pamir is i,nued. -
My Workers ora ..tion 1 uru,cc caner and Policy u
Carrier: $/l]��policy No.: w-
CL•RTIFlCATE OF IIArla1'I ION FROM WORKERS'
COMPENSATION INSUMNC'E 0O6 D g�jan 1
W
(Thi,section need not be completed doe perw,1,forme hudrtA dollen 181001 -
I.,any Net in the any mmutm ofthe wmkuto edch Ni,pnmiolonsued,l shall '
rotes Law anypersonii any mentorwul06ecmme,ubjal,o Nc Wooten'Compen- - ..
udrn Laws of Cdifomia.Date
Applicant
NOTICE.b APPLICANT:It,Corr making this Certificate or gumption,you uWulst i
bucomc scomly Nt Workers visions is provisions of de Labor Cob,you most
forthwith amply with such provisionsm Nis pcmi,alWlbuOeemed revoked.
CONSTRUC'nON LENDING AGENCY
I hereby affirm that Nem ifconetmcdo.leMingagency for Ne'mc..of
Z Ne work for which this permit is issued(Sm.3099,Civ.C.) x
Mew Lenders Name
�i 7 Leder'sAddress : - -
(aI Q 1 certify that 1 neve rib this application and slue she the above Nfomtsbon is
'W Z comet.I agree to comply with all city and county ordinances and state laws reb,ing to ., LIAPR �-menoses.abovememiored propene for inspection lcoe,ha.(We)agree w csave.osy indemnify W k«p hay in.the City of Npmino idCityQ V torn,secretL�dive ecis,he costsard et his luwhichnue in,ry way acme agarB said City iyg] inPPLICAcnc thegrTAN of Nia permit., 2000.API'LICA 'UN I!RB3'AND9A ' WILL COMPLY WITlI ALL NUN-IOINT 'U Z' sotl� 17
SignaturefApplicaryC to a -�
H RDOUS MATERIALS DISCLOSURE •� ��
Will the Appheant Or future Wilding occupant store or handle harallous materia ^Re-roofs —
as defined by the Cupertino Municiptl Code,Chapter 9.12.sed Ne Heahh and Safety
Code.Section 25532,p9 Type of Roof -
❑Yce ❑No t
Will the,'kit or future Wllding'm pun use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hazardous ah contaminants a,defined by Ov,Bey Arse AB Quality Management installed. If a roof is installed without first obtamilig an inspection
°"""°
❑Yes ONO I agree to remove all new niaterials for inspection. Applicant
- '. d
I have mad the hazardous mateddats
s no,dram , under Chapw695o(Ne Cdi- un erstands and will comply with all non point source regulations.
'forces Health It Safety Cade.Sections 25505,25533 end 25534.1 uderaud that if the -
buildi Dram beveaunun,,thus it is pomibiliryun JY eccupant -
fUse numew c m prim too a aft Cmifc f upemy.
re ,Signature of Applicant, Date
Owner or auN w agessDate
All roof coverings to be Class"B"or better
OFFICE