00030011 CITY OF CUPERTINO • PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: bQO 3Od
BUILDING ADf�2E55: y1/1
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cJa�/ktwa� eq �A 76, /�/(/• SANITARY NO APPI,ICA7IONS/11MµDATE
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ARCHITECT/ENGINEER ,yo/z BOLDING PERMIT INFO
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r z, LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Rat 1sur licensed under provisions of Chapter 9(commencing Job Description
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Gin fullfe andoffset.
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SO #AGel ��l�xe . ARCHITECTS DECLARATION Aep/�?e
I underrund my plan."I be used u public rtcardr
u.a a z Licamort Professional
OWNER-BUR.DER DECLARATION
t=z 1 hereby aRem has I un exempt from Or Contractors License Law for the
f'•O following reason.(Section 7031.3:Busi«ss and Pmfas[ion[Code:Any city Or worry
c3 a which mryu«a permit to construct.Blur.improve,demolish,m repair any somure S Ft. Floor Area Valuatiop `
prim to its i".'man,require,the appliesnt furnish p<mdl w fnle.signedauument q' �v
Nat he is licemed puauanTto the provisions of the Connotations U...law(Chapter 9
(commencing with Section 7000)of Division 3 of the Buaneu sed Professions Cods)in -
W,he it eeempt therefrom and de,basis for th<alagel exemption.Any vi dal of APN Number Occupancy Type
Section 7031.3 by may applicant for.pemut subjects the application to.civil peralry of Ln -
am more Nut five hundred dollen(S31)().
❑I.arnwner9rNepmp[sty,nrmy<mpiny«nwiNw.gea.,Neir.el<<ompemww, Required Inspections
will Prlmwork end TO,
Com;arotInU mo.doefm Wepply n3<4,Bualmu -
' tad erafwho Cade:The C es thers i Li«ase law dues trot apply a ser asv«e of
progeny who empltcaoy..
pr Improves thereon,and who
mis such work deed O r of Neagh
hisam own owe ere«,provided Nan such iced I,mrnu u<not intended ou oR[red for
ralmer-hawrewlha Wildingorimprovanent I,mid within oneild rorwmptgior the
ormse.mlder will have the When a/proving Net the did not Wild m improve for pas-
❑1.u owner ej ct Seoperty.c.704—exclusively eadusiveill sono-«ting with licensed ermadm', to
..Lo d prof«t(S«.7044,wmef and Profeuiom Code:)The Canosctora U.
law dwa not apply a an own«of pecpn(s wce Wilds rr improvhe Nerean.and
Lwho acer.Law.for each poj«u with acantnctmfa)licensed pvruent e the Contractors Q�
License law. ¢6y-
❑lam<x<mpt under Sec. .B R P C for this Janos
owner Data
WORKER'S COMPENSATION DECLARATION -
1 hereby af0nn under penalty of perjury one of the following declarations: -
a .haveandwillfor ynaum 37W of the aborCodinrurefurWmkeraceof<n-
tiw,es provided for by S«don 3700 of the Labor Code,for the performance of the
or which Nis permit is issued,
wo 1 have nd awill maintain Wodmrs Compensation Imurance,as required by Section
37M.1f the LaWr Code,for N[par for runce of the wort for which this permit is issued.
My Work yf�ptgp�nygy nsur.ntt crater roti Policy n
Gnier.��`ra/CERTIFICA Policy WORKERS' '
CERTIFICATE OF COMPENSATION
FROM WORKERS'
COMPENSATIONINSURANCE
(Thio secriw need not b<comPlned ifthe permit is forone hundred dollen(1100)
m Ione.)
I certify that in Ne perefmmane<of Ne work for whichthis p[mN is iseed,l,hall
not employ any person in any manner so aro become subj«r to Nn Worken'Compen.
senor Laws of California.Dau
Applum, .
NOTICE TO APPLICANT:IL after meting Nis Certificate of Exemption,you should
here.subject to Ne Wodrets Compensation provisions of On Labor Code,you..at
forthwith comply with such provisions or this permit&hall be d«mrd invoked.
CONSTRUCTION LENDING AGENCY
I hereby mlrmNat Nert is a c'unnum on larding"Sam"'for
the pefonnance of
rr the work for which Ni[permit is;swed(Seo.3097.Civ.C.)
C4 Lend,ex Name
(f• } fundi Address
W E 1 certify has 1 have reed dda epplicmm.and tame that the shove miurromon is
96 z corral.1 agree to comply wit all city and county ordinances and rine laws miming to
U O building conswction.and hereby auNmi«rape«nutivemf this city to enter upon the
move-me "
mi property for Inspection purposes.
GW [ti (We)age«m rave,indemnify and kap howlers Ne City of Cupnin.against
C V Ilshiludex,udgmems, cmimcfeapn« which may in any way.ccm<agmn said City
} W
I.comequ<nce of the 8.6,of this permit
F APPLICANT UNDERSTANDS AND WILL Cf]YPLY WITH ALL.NON-POINT
JZ) SOURCE RF.GUTATIO
Stgruurt NApplicarwConr/ fnyf, D n g•QN70A, Ur Cfa .
HI D MATERIALS DISCLOSURE'
Win Nc applicant or rumor Wilding mcupmtamre or handle hsrudam m.uial Re-roofs
se defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Sdmy
Code,S«uon V532(a)lType of Roof
❑Yes
Will the applic.m Of fnUM W;ldinga<wpen,Use[,piprcut or device,which All roofs shall be inspected prior to any roofing material being
[mis'hnallous air conuminanu udrfinW by Ne Bay Aro Av QWiry Manegcmcnr installed. If a roof is Installed without first obtaining an inspection
Y<s o I agree to remove all new materials for inspection. Applicant
❑
Ihave road the hv.,dms materials"p.hemems under Chapter 6.93 of Ne Cvi. understands and will comply with all non point source regulations.
fowls Health d safety Code,Sections 23503.25333 and 25534.1 understand that if the
WilNngdnra wteuerently haveaurwrt.thuit is mY r[spoasibilityenroti(Y the ecu t
of Nn requirem«u wJ ch mer be urn iss.of.Cmrficau of c p _
Signature of Ap c•nt Date
Ow«rde,authonize erg f Du
All roof coverings to be Class"B"or better
OFFICE