00040104 CITY OF CUPERTINO PERMITNO.
nult.mNO•nlvtSION PERMIT• - CONTRACTOR INFORMATION:
BUILDINGADDRESS: 'k
GO y SANITARY NO. APPLICATIIONN SUBMMAL DATE
—731
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PHONE
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_ .CHITEC`FMNGINEER s e.(.t l'/•v�� a �'G Cfb32-� BU LDINGPERMITiNFO
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'-�ML LICENSED CONTRACTOR'S DECLARATION
thereby affirm Net1son Ifuea pmvisioruo!CnaPuomme
r9fenting � ^ - ob Description
p,nt; WthSatan l000)ofDivisi n3afthe OcB.BuaimuaM R.fmiess Cade, my license is U{`/
lull force and Rect.
p U licence Cl is Lic.M QV ` � - 6a'�Cy
ARCHTfECT'S DEC ON (tJ'' v� ^vCVV�O�`Q k C [l(/`+•fit—V 11
v�<S .,1 un rsmrd my plans shall W nal as Public records A O �I /'��t
a a�'J 13cenud RofeuiorW ryp`(~ -/Jya - ry
OWNER-BUILDER DECLARATION
C 4¢ I hereby afBmm Nn 1 em exempt from the Contractor's Weems Lew for the _ -no ❑ following....(Section 7031.5,9uirem utd Professions Code:Any city or worry
w which rtquira a permit to cormwn,alter,improve,tlembliM,or ttpur any swcmre
as_ tanaiamanee,axa Sq:'F[. Floor Area - _�` •Valt�atn
'prim mgeircstheapplinnttorsuchpmnntofileecignadatetement CCJJ
that h<is llcemed Wrsuant.the provisiomof the Canuumra License Law(Cmpter 9' - '
(<e,he is ing with Sadad 40Eol of basis for the id ege inua eM on.An vo Code)or
Nat he is exempt thertfrom ast the mala forme mage exemption.Anyil resit of APN umber - ccupancy Type
not orm 703 LS by anyepddoll!orapermit mbjabthe epplicanno•civil perWry ofnot mart Nen five hundred dollars y employees
❑I,atawMrk,anepmperty,mmyomplendeawithwas"uNeWe(Secsole compenael.. Required Inspections '
will do professions
arAtheeuuCont isnot i License ed
l-aw does
otaMly.oan Busmen
and Property
-nob Code:The oyes then',and w Lew docs not apply himself lf owner of
progeny who builds or imPmves such i ore who does such work ded.or through - '• - ..
his own employees.provide Net ancv improvements art nu intended a offered for -
. e -Ixuf. oweaedse Wildingteburden
es'pcmem is sold did..
Wild roimprovefor the
,cm,
will revs the buNeh of proving metmdid nm Wilduimprove for pa-
pose of Wa). '•
I,as owaci of sm Property,am exclusively c..acti.g with licensed contrauces to
cons tNCI the project(Sec.70,14.Business and Professions Code:)Tm Connectme U.
cense law dos not apply to an owner of property who Wilds or improves themon,end
who...is for such projects wiNa n emgs)Iicensedp....Ot m the contractor., •° ''
License Law.
❑1 ptun erS d ,Bk PCfor Nisrtason
,w
,, s Date Y
WORKER'S COMPENSATION DECLARATION
i hereby a?ran under penNry of penury oro of the fol down.[declaa,iou:
I have
end will meinuinaCertiOcete o/Conuenuo elf-insert for Worker's Compcn-, -ion,as provided for by Section 3100 of the Labor Cade,for the perfoimence of the [Dj kforuehich this permit is issue.I have and win.amain Wmkee,Compensation Insurance,as require by Section of the Wr Cade,fns the perremance of the wwk for which this permit u issued.YW tis nor once carrier and Policy -eJI 11 ` O -CERTIFICATEOF SAnONIINN FROM E R ERS'COMPE pletcd N INSURANCE(Thissanianneednmmc.m Iced ifNc permit is faroc hurdre dollen(3100)
or Raafloy any that in linmy number amf s to be,forwhije tt to t emus is issued,hsCo i shall '
no employ my Person in any manner w n m.carne subject Nc workcie'Compen- "
.tion laws of CJifomia.Date
r Applicant '
NOTICE TO APPLICANT:IL after meting this Certificau of Eaemption,'you should ..
become subject to the Workers Compensation provisions of the L.bor Code,y.-must
forthwith comply with such provisions m this pemmi,stall W dame make. � , ,
CONSTRUCTION LENDING AGENCY
0 I hereby affirm the there is a construction lending agency for the performance of .s -
Z, Ne work for which this permit is issue(Sec.3091,Civ.C.) .. -
lacers Name
ori > undoes Addreu m
W A ,1 certify Nat i have read Nie application and stale that tan above infurudon is -
P4 correct.l agree to comply wit ell city eel county ordinances ae state laws relating to _
V O building constmctimi,and hereby announce tepreunutiva of this city to enter upon the - - - -
nbove-mentioned property be inspection pt rpreca
is. •�,i (We)agree m rove,indemnify and keep harmless the Cityof Cupertino.gains,
C.1 liabilities,judgments,costs and expenses which may in any way accrue against mid City
.�., (sl in consetewc of tan greadng of this t.
F A- AppLLCANTUNDERSfAND NI VI .COMPI.Y1VITfI AL1.NON fO1NT -
I) z IMM-011flUl. TIO
Signamreo AppdicanVComracmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will Neepplicaramfmurn building nttupentsrorear handle hanum ua mnurial Re-roofs
as defined by the Cuputino Municipal Code,Chapter 9.13,and the He"and Safety Type of Roof
Codio
Code,Smn M533(a)?
❑Yes -R -
All roofs shall be ins ected, rior to any roofing.Q material being
Will the applicant or future Wilding Occupant use equipment or divices which P P q b,
curt hazardous air c.Wrrinants as delved by the Bay Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
D`a° ' I a res to remov all new materials for inspection'. Applicant
❑Yu n.
_ LmvertW thcherardousma¢ntl. uimmenlsuMcrChaser 695ofNcCali- U ands and( 'll o ply'witli all non point source regulations.
C]
Health&Safety Code.Sad 25313 orad"M.I understand Out if
minently mvice¢nan t is arroyo,
to nosily this occupant
of requirefrlenrr icn s met ren ie sofa Ceri et of cup /
Signature of Applicant' Date
ow rmm' 'ae.Bem Dam -
All roof coverings to be Class"B"or better
OFFICE