00040028 CITY OF CUPERTINO PERMITNO.
BUIcmNG DIVISION PERMIT CO:NT ®R I I + ATIONc
BUILDING ADDRESS: V/,444r' T ^ u 4 rr;-
T7 SANITARY NO, APPLICATIONSUBMDTALOATE
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ARCH TECTIF.NGINEER RULD1WF1HtMffFjNI6
C�� /GtiGli NG. C �' 3
LICENSED CONTRACTOR'S DECLARATION
,,=E 1 herons aRrm Nu I am licensed under Provisions of Chapter 9(comnrncing Job Description
pml_•to with Section 70110)ofDivisim 3 of the Be,mr.anal Rofeuioos Cade dmy lismae is
<yfJ infullformandcReer
�mza U . lic.M 1NfB#-i4/ - T.T . '
X 3 a r Date Co.
A HrfELTS DEC IATION
fLLy a plan�je uxduPublic recoNa
a a Lice and n Profe nal ,,II
esS OWNER-BUH.DER DECORATION
f z< 1 hereby aRrm that 1 sum exempt from the Contractors License Law for the
5—a following,omn.(Section 7031.5,Business and Pmfassihm Cure:Any city or no,,
no which factors;is permit to consumer,eller,improve,demolish,or repair any menton
3_
prim to its issuance.alsascquimnheappliantforsuch pcmdtlofileasrc
igdatammem S F�IIoorArea Valuation
that he is licensed"..,to Else pmvisumaofme,Conoacmr.License Law(Clupttt 9
(commencing with Smuoh 7000)of Division3o(IheBmineas end Nhfeulou Code). APNNumber Oe ane Type
Nat he is exempt threaten.anti the basis for the alleged exemption,Any viohtion of pup y yP
Section,dom ire hun red dent ren.permit wbjmte tiro applicant m a civil penNtY of
not more Nan Bot hundred dollars y crops.
❑Li;ownmof the pin motor myer,immeerwiNwages as d.(Sole compensation, - Required Inspections
will dofewont,soda hes Conme istmts LMnse La ared does set
Rouse,ss
of
and Rofuhiob Cade:The Empower
thetofs License Law dens non apply s lf owner of
property who builds or improvsh Merton,and who alma such work himselforthrough
his own employe me Provided tmt such i.pohveold within...
thin nm insendcd m pRered for
ala l[however,the building m err of p wn lnold wild a t build oimprovetlo.rbe '
owdof Balder will have the buNrn of proving that he did not build m improve fm pow
pose of sale.). -
L as ower of the(Sm.
,Business exdus velyand mirPro emtin&wlth:icchedhe omenco 's m .
construct Ne es not pply o an wnoAM Property
who
Code:i proves b emon. nd
whoceaseclaw ilea not apply to us owner of pmpmy who builds or i.mavd Hereon,and
who contracts fm each projects with a chnbemor(q licensed pursuant to the Contractors
License law. '
❑lamdxempounder See. ,B&PCfor Nisreason
Owner -Date
WORKER'S COMPENSATION DECLARATION -
I hereby a?no under penury of pe Jury one of the following declarations:
I have and will maintain a Certificate of Consent to ulf-insum for Worker's Cooper. -
surtion,as provided for by Section 3700 of the Labor Code,for the performmce of the
- k for which mis permit is issued.
K .have and will maintain W.r se.Compensation Insurance,ee requimd by Section '
•3790 of ten Labor Code.for the performance of the work for which this permit is jou ed.
MY WorkybfgntpenytRAty(ry o canner and Parley h
My Wel/�L�lLnr Policy No,:
CERTIFICATE OF BXEMPfION IRO WORKERS'
COMPENSATION INSURANCE
(This sectihn mu duct uncompleted ifthe permit is foromhuMreJdollars(5100)
or less.) '
I certify that in the performance of the work for which this permit is issued,l shall
no employ any person in any mend,so as to become subject to the WoherY Compen-
"lion Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.Mer meting this Certificate of Eaemptims you should
bemove subject to the Worime,Compensation rowition,of me Labor Code,you most
forthwith comply with such provisions or Nis permit shall un doomed revoked. '
CONSTRUCTION LENDING AGENCY
Q I hereby ruffian that Nem iso construction leMingagedy fart.perfhmweeof
Z the week for which this permit it issued ISd.3W7,Civ.C.) '
LeMe's Name
('(s 7 Landers Address '
Lal S^ 1 cerhity,that 1 have read flux application and sum thth use,ahove information is
0. z const.l Agree to comply with WE city and tour,,mdiddes and sum hums relating neo ,
building comtrumon,and e thereby solvents representatives;or this city to enter upon the
U O -
above-mentioned properly fon inspection purposes.
[i E, (We)agree to save,indemnify and keep,harmless the City of Cupertino against
(„) liabilities judgments,costs anal expenses which may in any way aocroe against said City
�.1 W in consequence a the granting of this permit.
rF•w APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT
V Z SOI' CEREGUTATI 5,
of pplicet Due
HAZA ,
HAZARDOUS slum, AIS DISCLOS E
W"Ily da,Cupertino
furore Wilding e.Chaptemmor rehandle Health and Salty Re-roots
as defidd im the Cupertino Municipal Chile.Chapter 9.12,eM the IIee1N tad Safety
cme.s«tihhsss3zt.ll Type of Roof '
❑Yes �o
Will to applicantmfuture building occupant use equipment or devises which All roofs shall be inspected prior to any roofing material being
mit henrdoux air contaminants as defined by the Bay MCA Air Quality Management installed. If a roof is installed without first obtaining an inspection
E I agree to remove all new materials for inspection. Applicant
❑Yea o d
Imvere.d the merdtm matiel"rtgtiremema a.de,Gmptma.95 of the G.Ii- un erstands and will comply with all non point source regulations.
Tomas Has v r Safety Code, us inns ial, 35333 end Me,C 1 uMersuM Net cthe .
buildin8 dhee note n0y have mnant.Nat It is my ropnuibilay m notify the occupena _
ofthe r u 'c usI nm pncamiasuence ofd Cmdicoae
Oser uaNhn ns agent era Signature of Applicant Date
All roof coverings to be Class"B"or better
OFFICE
A