00050081 CITY OF CUPERTINO h- !� PERMITNO.
;AIRCHITH(TPENGINEER
IL UBUILDIING DIVISION PERMIT CONTRACTOR INFORMATIONy;"6qQQ �A kNpS Vr1 � ITARY NO. APPLICATION SUBMI AL DAT
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oN;:: S A2 A�SA .Z55 - 05q-7 q0L- go'7- 6010 9ULDING PERMIT'INFO
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t�F y fa^ LICENSED CONTRACTOWS DECLARATION
cO Z v,o I hemby affvm Net 1 sm licensed under provisions of ChahNer 9(commencing .1 SCllpll
Fy w with S.W.]000)ofDiA.lon3ofthe Business and Professions Code,and my license is - -
<y5'j in full force and effect. 1
� License class �-2& 'ut.x It ,/ �2�y-Qa.�.e sea- VvfineM
N Dale-z- �'O u Conuacwr 1
w 0 g ARCHITECTS DEC sUO
E 1 undersand my plana shall be used as public records. u
5�5 O O Licensed Professional
u� OWNER-BUILDER DECLARATION
'Zi am among,1 bersby aWW that 1 aamong,from the Convectors License taw for the
dF o following....(Section]031.5,Bmimss and Professions Cuda:Any city orcounty
W-m which mluirta a permit ro co mend,alter,impro«,demolish,or omeir any avunwe S Ft. Floor Area Valuation
n.3- Morro its issw«<.also a,over theapplicam forsuch permit sa fileasigaoaatement q'
that he is licensed Istormand to the provisions of the Convenors License Law(Chislam9
(commencing with Section 7M)of Division 3 of the Business end Professions Code)or APN NbaOccas
that he is e.e pt therefrom and the basis for the allegedxe
emption.Any v;elatu r Occupancy of w r i•e P Y Type
Section 7031.5 by any sppite=for a pemtil subject$the applicant to a civil anally of OL
cwt more than five hundnc l dollar(5500).
p 1.asewareruh<progeny,amyemploy«.withwag<a.aweiraoletnm«n„tion. Required Inspections
will dothework,and the he Cort isnrn In L. mos,does
Wy]049,Business
clad Pofualob Code:The Cor there's,and w law does nth apply as lf owner gh
his own who Wilds or improves such i and who don such work steel cir«eed gh
for
his own employethe provided r i such impmv<mid w thin not inanded a oHercd for
We IL havese will
Wiringman of Moving
is ental withinone year of covmle for Oho
-Wilder will nae the Wrden or paving that W aid not Wild a impose for par. ..wise
h w owner of the propcny,son exclusively contracting with licensed comramore to
onse La the project(Smapply
]Odd,weer of and Professions or
The Contractors nal
cense law dose not applyje an with
owner of pspeny who Wilds p or impruves thereon,pts
who contracts f«sato prol«t$with a contractor(s)licensed punuent a the Convacah
License law. /
of un exempt moor Sm. .B R P C le this rust A
V
owner Gate •1
WORKER'S COMPENSATION DECLARATION V
i hereby alma tier penalty of perjury,arc of the following decsre-Con
❑1 have end will for by
eCmiO7W of Consent r seaic,for
fee Wmkera ce of ttl-
he
anion, r povided for so Section 3]00 of the Labor Cade,for the pedomunce of the
work for which this permit is issued.
1 have and will maintain Worker's Campefthion Insurance. aq
as utW by Section
3]OOof the laWr Coale,fa thr perlormurc of ten work for which
ch Nis permit is iswed.
My w�nf�mperration Insurance rapier and Policy n b�e�arg�036 O
Cavicc An.0 VA Policy No
CERTIFICATE
CERTIFICATE OF EKFMPIION FROM WORKERS'
COMPENSATION INSURANCE
(This section need no be completed irthepenoit is forum hundred dollars($100)
or less.)
1«nify tut in the MRodnaac of the wort for which this permit is issued,)shall
not employ any person in any manner so as ro become .bj«uo the Wm ons,Comp.-
mono laws of California.Data
Applicant
NOTICE TO APPLICAM':If,afar making this Cer ificete of Exemption,you Amid
Menne auh*t to the Wmkars Compenation provisions of the labor Code,you must
foMwith comply with such provisions or this permit Nall W deemW mokad.
CONSTRUCTION LENDING AGENCY
Q I herby alrm that them is a construction leading ag<noy for the perfomunoe of
Z the work fm which this remit is issued(Sec.3097,Civ.C.)
Leaders Nune
>_ Leaders Addmese
[� I codify that 1 base read this application and sate that be dove infomatien is
d ^� comate.l agmen to comply with dl city and county eminences and sate laws colicas m
.7 Z building construction,and heeebyaudmdm ropeeeonwiv«of this city w anw,upon the
U C above-mentioned propny for inspectim PmMO,s.
L. 1:. (we)agree to ave,indemnify and keep humleu tW City of Cupertino against
f, liebilite;judgments,cora and expenses which may in any way acerae against said City
>. W in consequence of the granting of this MOOR.
(• h APPLICANT UNDiRSTANDSAND WII.LCO. LYWITOALLNON-POINT
V z SO Hi REGULATI NS.
f S -12-r2
g of A,I, UCnntatm Dow
HAZARDOUS MATERIALS DISCLOSURE-
will
ISCLOSUREwill ths.,icantorfuture Widing occupentncreom handle losandoo..,ad-) Re-roofs
so defined by the Cupeninu Municipal Code.Chapter 9.12,clad the Health sed Safety Type Ot ROOT
Codr,Smim 25532(.)]
❑Ycs ONO
Will the applicant or future building occupant use mcipmett or devices which All roofs shall be inspected prior to any roofing material being
mit haramdous atr commumna as defncd by the Bay Am AG Quality Manegrmcm installed. If a roof is Installed without first obtaining an inspection
°1BNe"
❑Y ONO I agree to remove all new materials for inspection. Applicant
00 Ihave read the haadous rnswdals eequirtmena under Chapter 6,95 off Csi- u❑ erstands and will comply with all non point source regulations.
ferns Hwlth A,Safety Code.Sections 25505.25533 and 25534.1 undersand that if the
building does coal currently nasi a scrag then it is my responsibility to notify the occupant
Nc_segmrcmems wy�2n�""th t «e ofe Ccnifcvu or act,
uy{� yes• nth S"
/t- Signature of Applicant Date
)w r authod agent Dat
All roof coverings to be Class"B"or better
OFFICE