00040126+ CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT,
BUILDING ADDRESS:
SANITARY NO- APPL1 ATIONSUehq AL ATE.
OWN/ 'SNA
+.
1 .I
N/C CONTROL#
a s:
ARCHITGCTIE GINEF,R
O
'
LZNSED CONTRA R S DECLARATION•
S=Q 1 hereby a1R, dust l am hccnud warp ions of CMpnr 9(common I g Job-beserlption
I
H v O wrU Section 7000)of D' - n3 of the,Busin aw professions Cade and my liccrue,s —��. { '•e I
6
a. fame.w<fie<t '• .�
mec
3 u O 'Llxnu Class'
Nic
I.,u O6 CTS DECLARATION
n rst I n,puaic recordsIt
., QYe " ,NIC cr• ULQ• ,
X o W .sedonal - w
w y ' 'OWN BDER DECLARATION,v ,
< I ereby eRrm Nat I exempt boat she Convector's License Law for the ,
E o full -g rca (Section 7031 3,Bueani s and profession,Codu MY city m county
vi which em uves e,permlt to crn,tmcv shot massive.demolish - pair any stmrnve - - .. -
d a Sq. F[ F or ea Valuation
-
.anor 1.IN kiatunce,
parWneat requires theapphcrnt for such pmrmttfleaintend(htunrnt
that he is licensed -licensednad uanU the provisions of she Crnwdo/e IJtrn Law(Chapter
�(com mingwi Sauon7W)ofDivision]of Ue Bualnusmrdprofessions Cade)m APNum O Type
Wt he is exempt Uerebrom and the basis for the alleged exemption.Any violam n of er ll pane y yp
Section 7031.5 by soy applicant fora permit subjects the applicant to a civil pen,lly of `� J • - - ,
not more Nen five hundred dollars(5500).• J ' _
pl,as n6mermth<progeny.mmr<mployees wier wages es theirsae Pampens680., - Required,Inspections
will do Uc woh,andthesvucnrcis not invnddoroRerd finale(Sec.]094.Budnevs
endProfessions Code:The Contractor's Lieu.Law does am apply to xe owner of
1• property who builds or improves thereon,aw who does such work himself m through
his awn employees,providd the inch improvements ere Dol intended car oReod for
sale.ILhmvesenthhave thingmimprovaatent is be
did son<yeuoimprove fon,thc' - ..
owneohilder will have the burden of provin6 Ueo he did not build m improve for pu}- {•;
Wee os'..). -
mothe
L sect thea of the progeny,on exclusively Proved:..Con,od:) no Ccontractors i- '
cease Law
thoes not t(Sec:o an Business and Professions Code:) ConhwroFs nd
who ombdxanotapplymm ownerobproWns who builders turnover Uaeon,end
License radsfor such pcbjecn wiUaconvacmr(s)licensed pursuant to me Contractors -
❑I am exempt under Sec. B&PCfm Uis reason, r
.. Owner ram r
. 'WORKERSCOMPENSATIONDECLARATION'' "'
Y1 andwill mi de Welty ofofCo mwofthefill ghave Ww time -
m,asendwe lot by eCre,17 a ofCon,enalr rode,fa for Wmkow Compen -
moron as provided for by is to 3]00 of the Labor Code,fm the perfomwnce of the
oh for it ills W t d - r '
I have it wilor m lei herkrfo CompensationthIrkfarwhich
his perdby Sat
ion
My obthel.abm Cade i thepancemance tithe lick far wh hUr pertni�ia ie cd '
My Wmkels Compensation Insurance comm and Pohry number ism
.Camcr. - Policy - '
CERTIFICATE OF IINN FROM WORKERS
COMPENSATION INSURANCE
(]hrs saran need not be completed if the p[I(Nrufor con,hudrcddollan(S 100)
Ioy an persnia rbormeer mate W .asbje thin ew iioss,Ci m- -
"mm�se Law any Wrsan in any manna:ao m m bcuome subject ro the Wrrkcra'Grogan-'
Applicant Laws of Glifomie.pard ..
ADPlicenl
NOTICE TO APPLICANT:If,after making Uis Cmdficav of Exemption,you should' ^
-.hecomc subject to the Wrdam,Compensation provision,of she Labor Code,You most
forthwith complYwithoch provisions or.this pemrio ahell h damdcooked.
A
CONSTRUC710NLE.NDINGAGENCY. x"
•�•Q c
lhaebyaR.m tUercisacons(metlonlewmgagencyforNepe orf r of
rte/,
the work for which this permit Is issued(Sec.309],Civ C)"
4
Lenders Name . - -
�(, >' 'LondeesAddreaa
[� I comfy that 1 have read this epF)icauon end and,dust the above ofoinafrn is
d A correct.l alone,m comply w W all city erM county acdounca aw ma R,law,sela6ng to
- -
a7 z Widi instruction, hereby uthrri ntive t h enIs
I c n end he a urc am sof lust w res nUe
ng Y Pre Y W ,
C.) P -above ate..r.d propene for lnspaiian Imp.ha'
R.�y (We)agreeto save,andexpenand keep hay in m UeCity ofCaparisongaminsideates r ^
0 V liabdiuea,rydgmrnts.costs and expenses which may in any way eccme againn mid City, -
ryi mequ nee of Bw&,anofpermit„ L -
Fw
rAPPLI , ND WILL O LY WITH ALI. N-�Lav
TC MPO' .RF.( !de i a " " a
4 igw f ppbcanUcon ;i •. Date // ., �O `
H US MATERIALS DISCLOSU
'
/will the epplicent utumbuildog.ccupantsmmorhandlehue ousmarcnal` Re-ro0 S s ^ k •^ /
as defined by the Caprifinu Municipal Cole Chapter 9.12 and!the Health and Safety •."
Code,Session 25532(.) ' Type of Roof.'•'" .r ,"
[:1 Yes
Will the mpircanto fmure building me pant useequpmew or devices which All•i'oofs shall be inspected prior to an yy `roofing material being>
emit huardrus air conmmma.n as defined by the Bay Area Au Quality Management • installed:Ifa-roof is Installed without first obtaining an inspection
District?
��L,j,/(�� - ` � ` IL to�remove`all new materials•for.inspection. Applicant
Y. / .,} a, d
t Ihav<rcdBreheaardousmetmalercgmrtmennuwerC'Iwptah.95N,Cali- un erstands.and`will comply with all non point source regulations.
tomo H<al ,fay Code,S 25305,25533 mW 25534.1 wI if dwbuildin' n t he i,that it ismYmsponubilit Ncupantre 'rrmrssuence ofa d - '
Signature of Applicant Date
- "sed agent Data
- ^ "
All roof coverings to be Class"B"or better '
OFFICE