00020155 CITY OF CUPERTINO PERMITNO.
ItDILDINC DIVISION PERMIT CONTRACTOR INFORMATION: o00 0-i C)
BUILDING ADDRESS:, S+
ANI'ARYNO APPLICATION SUBMITTAL GAT
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ARC[I II' Cf/I?NG I NEER _ 5•V_��- —� '�� DULDING PERMIT INFO '
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t-J i LICENSED CONTRACTOR'S DECons of CDN
ZO„- 1MebralRrmmatl.mu<em<d.merpm.iaenaPrcn.pler9f=nmmen<ing Job Description
OZFC with Section T000)of Division Jofmr Bumnuciard PmfummsCoda,ano my limine is
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K G in full(oche and eRc L� �''') N� / ,.s/1 rN� ,S t /N e
D d u Liceme Cle s -,,c*-
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LLL O¢ AR S DECLARA N
LL y I ars m if puWar records
W g`O O 'Llcensd Pro ersional
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OWNER-BUILDER ECLARATION
t Z 1 hereby aRw mat 1 am exempt from me Contractors Licosa 4w for to
H O following season. ermitrn'f031.5, t.War,
ab Frufesilws Cade:Any .ity m county
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which tots m o permit re cmnwe, inter impose,demotion,or repair ani swmue Sq. FL Floor Area Valuari�
pdmto its romance,also requircsthe appliomfor such pemulmEle uLnedshptem y
chat aislimfued Su ..rotheofvvionsofof BusinoYsl.i«n«law(Ceder9 (boo
(commrming wipe Senior gtllp)of DivisionJofda BusineuaM Profeuiou Cadelui ped Number Occupancy Type
that be is escmpt mmrfrom W the basis for me alleged exemplum.Any violation of ^ J�1 �• q P Y YP
Section 7031.5 by any applicant for a pewit subjects the applicant a civil pennity of a41a—tJ{ 'TAM a
pOut mon,Nen f ve hundred dollars(5500).
1,asownermrflscprpedy.nrmr<many«.wimw.goasmehmlebompemstinr. Required Inspections
willdothe work,endure rwcturt is trot intended moll<r<d fm sale(S«.1014,Bmircas
and Professions Cade:The Co mulm's Liceme law doer trot apply to an owner Of
property who builds or improv«Ihomon,and who dots such work himself m though
his own employers,provided that such improvements art not intended m offered for
sale.if,however,the Wilding or imPmvcmmt Is sold within one yearof mmplation,the
ownenbuilder will have me Ween of prvving that he did not Wild a improve for For-
pvcof.a.).
❑I,a caner of me property,am exclusively contracting with licensed contractors to
construct the project(Sm.IDW,Business std Professions CudeO The Contractors Li -
ceuc taw does rot apply to an owner of property wed Wilda or improv.thmem,red
wedmform s for such peri with a contra um s)licevcl purs«nt m fair Connectors
Licrose law.
l am exempt under Su. .B A P C for this o uun O
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby aMrm under penalty of perjury one of Ne following declaratlma:
]I have and will maintain a Certificate orCou«tmselGinsumfor Workers Compcn-
sation.as provided for by Section 3700 of and labor Code.fm the performance of the
work for which this pewit is iuued.
®®1 have and will maintain Worker's Compensation Inaurence,as required by Section
lllglof the LaWr Code,for the perf rrus.of the work for which his permit is issued.
y Worker's �smali and Policy number art:
Cardec C:�. rvs"Qeceni«Polity No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This.0sm nod nm W completed if the pewit is formic hundred dollen(SIM)
or las.)
I certify that in the perfc.of Be work(or which this profit is found.I shill
int employ any person in any manor m as to bmorne subject to the Wooten'Comm—
sation laws of Coliforms.Data
Applicant
NOTICE TO APPLICANT:If.afar making this Cedificate of Earmption,you should
haeme aabjmt to the Workers Compensation Provisions of Ne LeWr Code,You mon
foMwim comply with such provisions or this pewit sell be d«med revoked.
CONSTRUCTION LENDING AGENCY
� � kforhereby which
thatmcre Issued(m.33097,lending agency forthrpMmmance of BUSINESS
z � me wink for which Nu pcwin is issued(Sm.J09I,Civ.CJ
endcra Name
Z y en
Lders Address
l" 1 crNfy,that l have mad Nis apFllcniun and stale met Ne above infmmution is
C. Z building I agree tocomply a d with ill city arm ewmy natives es and nine laws t upon
r, LICENSE
'C E N S
7 Z building construction,durrovW hen,by amtionu pme..representatives oda city no enter upon me
V Q abnv[ 'We)red pmpave fm lr5pS11nn keep ha.
W Es
'We)spree'.
indemnifyand k«p hawlwsthe City raCupertino against
O W limossu.jodgmm,worm,c pensaanful. may in any wiry accrve agilnxn said City
>. Vi incURIPcmc UIme granfin8 of oris permit. REQUIRED
F 0- APPLICANT uNDERSTANB�S AND W 11.1.COMPLY WITH AIJ.NON-POINT
U SOUN(g�ttliGu (INS.It .w
//fiTo, m U a A —I Data
Sib fApplr uCom fm Data
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or(mure Wilding mcupem pore or handle huudws material Re-roofs '
as defined by the Cupertino Municipal c,Chapter 9.12,and me Health and Safety Type of Roof
Code.Stolen 25532N YP
0 Vrs
Will lhr applicant or future building occupmt tau equipment or devices which All roofs shall be inspected prior to any roofing material being.
it hauNoua air contamimm�as de ned by me Bay Arca Au Quality Management installed. If a roof is Installed without first obtaining an inspection
Nrt aka I agree to remove all new materials for inspection. Applicant
'. t]Yea ,
—I hudoaddreharardous materials immommn miner ChaPar 695nfmr Cali- unclerstands and will comply with all non point source regulations.
fomu Hglm&Safety Code Savors 255(15,M533 and 25534.1 understand mal if me
Wildingfpcs nd cumnuY f I. 'o is mrmpor.cruillone fyma«.pent
;fora ,Am/a Via/hie m ismy noon Cmrecneof Rcuprcy.
OI 2—le-6g) Signature of Applicant Date
(TvnTrYe odred ag n Dale
All roof coverings to be Class"B"or better
OFFICE