00040052 CITY OF CUPERTINO PERIVIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
SANITARY NO. APPLICATION SUBMnTAL DATE
Ll�/o--0
OW NAME:'R" / L
. � i� /`f"I/ we CONTROLp
C• n BULUING I'Ii11MIT INFO
.ItCHIfECrIIiNGINELR
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S N LICENSED CONTRACTOR'S DECLARATION
I hereby affim Nun
rat I IicrnsM uder pmvisiom of Ch,ptcr 9(commencing / Job Description
c C l iwnicnenISIRafrreare 0)oJf Diii3f NBLic.iN aM Rofeuiom CodealM my licenu is ./1��!/` r�^/'rf�(VZ//� t•� G �/ /y
70
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ULiNCU
a O eJ AbeCCS DECLARATION
c <5 I underssaM mY Planss"sled I beM usM public records
re
''o.G O ff
mewed Prefeuloml
p OWNER-BIM ERDECLARATION
1 hereby afrmthat 1 am exempt from Ne Contractor's License Law for the
P€O following Rasa..(Sceim 7031.5.Business and Prefmions Code:Any city or county
co WIdLM1RgYIRiapereltWcamtfucl,al1e51mpmK.dCmOhN,mrtpYrNy6OWanrt 5 Ft. Floor Area Valuation
prior 10 its issuance.also requires the applicant for such Pcmdt to file a signed statement q'
'U`-'
Met he is licensed punuam m Ne PRvisiom of Ne Canmmteee license law(Chapl.9 �� S
(commencing with Section 7000)ef Division 3 of Ne Business and Profesaiom Code)ca APN Number occupancy Type
Nat he is exempt thcrtrom and the basis for Ne alleged exemption.Any violation a
Section 7031.5 by any Applicant for a permit subjects the spli icannno a civil penalty of a 7
pN mart Nan five hundred dollars($500).
I.aaawmrarNepmpeny,dmyemployea,w;mw,gaa.,NeiraaleemnPel.,.dm,, Required Inspections
will dolewmk.Code: he Con is Imiimm�ddmeRem4for apply
Loan Budrca
and property
whom Cie:The Contrrcmes License who
law does not apply la lf mvn.M
progeny who build.or improves,ancon,,rd who does such wok himself ti through
his own oweveras,provided Wt omen irson is roma art mil inaMed i oif.ed for
sale,ILudderwthe Wildingorimprovement is coldwithint yearofmproveior the
-WildawillNKthe WNen of proving Net he did net build or improve for pw- Ar��
pose os,ow L
sa l(Vl`
1, owner of ct property,am exclusively c9nnmdng Cod:)The
nnmmmrs i
construct the es ed appl(Sary
o an owner
of and ns,wh mom Code i The ConOmmr,Li
who,lawdoesnalapplyines own.of premx(s coed Wildsori '-M Neon,and
collo cse Law. ar such pRjaa wiNeconwLmr(s)Ikemd punuantm Nc Conlaxtofs ` v
D Ts taw. 0
1 em exempt under Sm. .B,k P C for this roman
owner Dem
WORKERS COMPENSATION DECI-ARAT10N
I hereby afirm uMer pmaltY of perjwy ane of dro following declarations:
(neve aM will msmnxm&CenificateafC mntmssl6imom for Worker.Compem
tion.es 5 u.for
by Sadon 37M of the Labor Cie,for the peframesre of the
work fw which tha permit is issue.
❑1 have anal will maintain Wmkers Compensation Insurance,m required by Section -
3700ofNe LsWr Code.fm Neperformantt of dm work for which this permit Is maul.
myx
Caaeoh OC CERTIFlCATE OF E. EMPTIONofirPoROM WORKERS'Oj���l q
COMPENSATION INSURANCE D p pD 1 O LOoo
(TTir uednn held nal becompleedifNe pemdt iafwonc huMrM ddlua(SI00) Ijr/�
or leu.)
Icenifythmiet pert eof Newwkfwwhich Nl,peatitisi.M,Ishal1
not employ any pee y I�^v^t�^fpe�r hJL ape dub t to the Wmkcn'Compete
cation lawaofC �fyV
Applicant 7 o f
NOTICE TO APPLICANT:If,after making this Cenificee a Exemption,you should
become subject to the Oversees Compensation provisions of rte Lobar Cade,you must
fonbwith comply win such Previsions or this permit WII be doemod evoked.
CONSTRUCTION LENDING AGENCY
O O Ihereby afirm that Mere is,construction landing agency for the performance of
Z Ne work for which this permit is issued(Seer 3097,Civ.C.)
t:. toLLMees Name
a � IaMels Address
fT] 1 certify Nat 1 have read this.,dwistion and some that on above information is
d conal.I agree to comply with all city aM county ddinmcca aM wan laws almir, to
Z Wildin,,crecadon,and hereby zedmria rtpreRnatives of Nix city to enter upon the
V O above.rrcntiend property for impaucm purposes.
is E~ (Wc)agree m saK,iMermify and k.p nleu the City of Cupenine against
O U u,mudaJaegment,Lera.M eapypar-arry.-Y.-C.-.gainal a.ln aqnc nacgeeri d e mining of N' a {1 DSTANI 'APLY WITH ALL NON"M)INT
U 5 URCP fi)f ION..
ign Iicand ARD m Dale y�� C fir
HAZARDMATERIALS DISCLOSURE 'l•
Wilaetfmum Wilding smaor Mee amterial Re-roofs
defined by da Cupertino MunicipalCds,Chapter 9.12.cori Ne HeWthanSafety
Core. ss532(01. TYPe of R
oof
Yes I_yrvo
Will the applicant orfuture Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being.
"glokemtha masurLwmaminmlaa.drRmdbyMeBay Art.Air Quality Management installed. If a roof is Installed without first obtaining an inspection
iatrict7 P40 I a gee to remove all new materials for inspection. Applicant
ON Yes
Iluvc the hat rddm�ammti.b requirtmenaunder Chapter 6.95 of Or Cali- un erstands and will comply with all non point source regulations.
foam,Hmlth Safety Ceay fu s 25w5,25SJ3 tad 2553..I uMersuM that if the
tuiLOn o pa rR 11Y 1e lemm.Nu it is my saponsibility m notify ll'e aavpmt
of u'rmusu 'll f16e nom prIX m iYWIKC Of,C'.Id fL'aI01K)'.
�/ /d/ D Signature of Applicant Date
O or euNorizM agent Dam
All roof coverings to be Class`B"or better
OFFICE
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