00120150 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: Q Q / S0
BUILDING ADDRESS: PERMIT NO.
zZ v a b e b/4k
OWNER'S NAME: APPLICATION SUB DAI'IS
' PHONE: SANITARY NO. CONTROL NO.
O-Z AHCIIIT ECT/ENGINEER: BUILDING PERMIT INFO
L&' _ r:LECT PLUME MF,CH
ZOyZ' LICENSEDCONTRACTOR'SDECLARATION Job Description
1 hereby alrrat that I am licensed under prosWom.of Chapter 9(commencing .
with Section 700(rof Us Who 3 ofmc Bminess and Prom,,i...Code.and my license
a mfull force.m B
Sym¢ Lin icense C'yl.. 9 ` Lic
ic,
)all
u1 5 W G AHChall be use Ds lathe esa
C=LLary O g 1 understand my plum shall he used as Iwhlic¢coN..
e5 p zLicenceKro
d l...onal
�fce, OWNER-BUILDER DECI,ARAI'ION
ul v 1 hereby affirm that I am exempt from the Contractor's License Law for the
t_ follox'ing mason.(Section 91131.5.Bosuns,and Professions Code:Ano city or a,mny
a C which 5yuiras.n hermit to enmWcr,ulleq improve.Jnnalish,or repair any struclum
r�3g nrinrtn its issna".nHorcgnlrmthc apnnemn lareurlf,rnhm file usignrdeammcn'
e that lie i,elicensed pursuant a1heprnviImn.nfthe cmrw„nr.LicemeI",Craptef9 Sq. FL Floor Area Valuation
msmarrencing widr Section 71001 of Division 3 of the Basin—and Pmf...inn,Code) '
or that he is exempt therefrom and the basis for the alleged e,mnptlon.Any violation '
lin Section 7031.5 by any applicant for a permit,objects the applicant to a civil penalty
of 3I more man five hamned dnlErs(5500). APN Number Occupancy Type
O 1.as owner oflhe propcny,fir my employees with wages as their side compemwtion.
rill do the work,add the rmanom is not intended at offered for sale(Sec.70,cL
nosiness and Professions Codc:The Contractor.License Law arcs n d apply m,an Required Inspections
fir prty Who s build imp ae Iheram,ail ta
who docs ch work hi stiff -
.r Ihompc
mgh hl,own c mployccs,provided amt such iinfr ur
cs tic not Immirded or
alfdrcd for sale.ICv hnwwer,the building of iirymnvammnt n sold within ane year of
imrprovei for the owner-builder will have the buntrn nl proving that he did nm FuiIJ or
prme rpt pato"e armed.
❑I,: of the Propuny,n xeto,ively smnuaaing wish litxmml cornasOor,
Lm.aructt the project(Sec.TW.Business and Prof,%omis Crmea The Contractor's
icense Law does not apply to an owner of prolcny who bmI&or improves thereon,
and who contracts for ouch pmjectn with a conlmaor0)licensed pursuant it,the
Ownmcmr's Liccnsc Luw.
m
❑ ac-smnp'under Sec. .B&P C for tideruaaun
Owner
Dam
WORKER'S COMPENSATION DECLARATION
I net Elkton undo Iamalry of perinry nnc of the fallowing dcdarudo s
❑ 1 have and %ill maintain a Certificate of Consent to sel6insom far Worker'.
Compe3smfon, as provided for by Section 3710 of the Labor Cale, for the
perlinmance of the work for which this permit is issued. /
❑1 have and will maintain Wnrset',Crnnnen.vaion Insurance,as m uimd by Section J j
3110 of the Lala Cale,for the performance of the work for which this pemrit is
i.esunL My Worker's Compensation lroumnce carrier and Policy number are: 9
Conic[ Poli,No.: /
CEMfI PICA IION OF HXEM Pf10N FROM WOR K LRS'
COMPENSATION INSURANCES
('1'his.ectiun need not be completed if the permit is for one hundred dollars
S IW)sir less)
I ccnidy'hal in the pe,M mane of the work Iia which this permit is I...ed.1
shall not employ any person in any manna s,s m, uM1Ret to Worker'
Comlcnsut Ln �C'Ify yams / c� ZY Ori
A VE
NOTICE'I O APVLICAN'1:II:ager nnuCing th (cnlficrW of Imah,'ion.Ynu IhnuW
M1eeome subject the W'orker's Coml,ensminn trustprevisions of the labor Calc,you nc'
Q C forthwith comply with such provision,or,hi,permit shall be deen¢d 2,aked.
.~Ns CONS'rRUCI'ION LENDING AGENCY
a ' I herchy atfimn that mere is a cnaom',,on Iendbg agency firth,pcnurnnnmr
of the work for which this permit is issued(Sec.3R)7,Civ.Cr
C,aQ Lcndvr's Nam
Q z lender's Addrese
V I ccnily that I have head Ihi,if,riaatinn and ,are that the above 13I'or5alino Ls
fzs E. morcel.1 r,mc 5n comply with all city and counry ordme3ces and state laws mitamg
Q (� rebuildingcoremaction.and hereby amlamiemprruned",or this city to enter a,.
the aF.rvcnmnlioned Mope t,far inspection pu'ry,.es.
F d
(We)Egan I.save.indemnity and keep harade.s the City of Caperina ageihw
V) liabilities,judg3enu,n,stx and rs,r.cs which may in any way nee ruu'gninw said
V z City in con"mnre of the grthong of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON-POINT IssuedDate
SOURCE REGULATIONS, y'
Sigtammof A"Icnu/Cnumnar Inti Re-roofs
IIAZARDOUS MATERIALS DISCLOSURES
Will the Whe.nua future buildin,mv.pmt samor handle hvallomtmenul Type of Roof
as defined by the Cupertino Municipal Come.Chapter 9.12,and the Health and Safe,,
Code.Section 255320)7
CI Y3, ❑No - All roofs shall be inspected prior to any roofing material being installed.
Will he aptheantrn mere building necanmd ma,egrdpmvmor desires which If a roof is installed without first obtaining an inspection, I agree to remove
emit bamrdnus air cnnmmmants as ddned by the Bay Area Air Comity Management
Di.anen all new materials for inspection. Applicant understands and will comply with
ave, oma all non-point source regulations
I have mad the ety Code.notion,s 505.255331. dunder255 Chapter 695 0l the
ithe brian,berth&Safety Cs,de,asclh,ro255D at ifN n nv,psn J.1 um le rod
that
ifthe build leg docs not mrrifrahly,'In , a t ant.mat if my rcnpxn c If lrym ificah rbc ! T
oecnpum nl the � oma which moot he nm5 pilar m issuance nl a Cenitisnm of
OIcupan terse
ure Ap :cant Dale
.owl --mcdagent Date Si lAll roof coverings to be Class"B" or better
OFFICE