00060188 CITY OF CUPERTINO
BUILDING DIVISIONPE RMIII IT _ CONTRACTOR INFORMATION:
SS.
BUILTG AD 'FRAn/ O
OWNER'S A flu
AI'I'LICA'T-IIl`ON$UUG DATIi
HONK: pe SANITARY NO ' CONTROLNO.
LOOT 3L�- -/ 709 a QS/ Z
QCO ARCHITECDENGINEER: BUILDING PERMIT INFO
pp BLDG Io.E PLUMB MECH
myFty. w
LICENSED C
ICEO 'OR'S DECLARATION n /v/
/ Job DCSCIIPt1On
OZ I hcmbyinm That Ima llowdoodtt pan ionoofl Charter,t(comieenng
ih Smon]XXbor Dvision3oflhc hmmc'unJ pnfessiom Gxlu,snot my license 20 qMp
Y
m is in full force snot
i O Licence CI: a AR _ Sic.-r.7
�' 3o d/ Cnmrannrti
vi 3 a Doc_ --
\RCHITECT'SUEChARA' U'
C°—'�� 1 umlcntanJ my plans shall he uuJ ac public mromh ,
pp Licensed Profcesionnl
o OWNER-BUILDER DLCLARAI'ION
I hereby affirm that I am exempt from the Commerce%License Law for the
following mason.(Section 7031.5,Runic%and Professions Code:Any city m county
�5 O whah"'Imes a permit It, oar c,denaili li.o,repair say mracmre
prio lin its issuance.also requirestbe applicant lnrmch ptrmino file a signed statement
mat rte is lin«n'eJ parsnanl lm me proWsnama Drone cantraemrn ueemse law lemprer9 Sq. Ft. Floor Area Valuation
(commencing x ith Seniors 91XXB of Urviaon 3 of the Hmorcc%and Professions Code)
or Ihm he in samosa memfrnin snot nm Kuria oa the alleged esemption.Any violminn
of Section 7031.5 by any applicant for a permit%objects me applicant to a civil penally APN Number Occupancy
.four reotc than fisc hundred dollars($500). P y Type
Cl L as owner of the pmpnvy.or mymnFluycex with wage'w their sole coo.pensaninu, —3 / 'Q•��
will do the work.and the swcture is not intended or olfemd for sale(See.]aa' Re sired Inspections
Business and professions Code The Contractors License law does not apply as m q P
rot pmixny Who builds or imposes thereon,and who does such work himself
or through his own cmpluyecs provitl tone such Itop.ovcmous are not intended nr
offered ur sale.It.however,the building or impreemem is sold within one year of
curnplerim.for the owner-builder will have rbc burden of proving Ihnl he cartoon build or
Imposerot parjois,he.,n r- ilde ,
Ol.as owner of the property.am exclusively contracting with licensed contractors to - /
construct the project(See.]OW,Business and professions C«Ie:)'Me Contrucmr'c
iense Inw doer not apply man owner of property who builds m improves to lit,
and who conwes for such Pon ca with n eomy who al ills sedor
proves l thereon,
the
Contractors am exe License Law.
❑I um exempt unser ase.Sec. .B k P C for this rax
Owner Ilam -
WORKER'S CONIVENSATION DECLARATION (�
1 hereby mGnn Boder porol y of perjury one of the following declnn'turs: v
❑ 1 have and will andol in a Certificate of Consent Iso seif-insure for W'orker's
Compcnsarion. m prmided for by Section 37W of the labor Cade, for the
I"rf anuence of the work liar which fhb pen at Is issued.
fhave sed will maintain W'orkei s Compensation Insurance,as required by Section
]1X1 of the Luber Code,for We performance or the work for which nhisipermir is
iccncd.My Was C Bps l"loolo ce uaoicr/nnd Policy uumhe(Iso
Carricr: l=,'-(icy Nn.:�(L7—00—r76 8 .
CERTIFICATION(lir ICKEMPrION FROM W'ORK17RS'
COMPI?NSAI ION INSURANCE
(This section need not W eonnpfeted if the permit is for one hundred dollars
IS I Donor level
1 cenily that in the performance of the work for which this permit is issued.I
shall not employ any person in any manner so as to become subject to the Workers'
Cmtgencminn Lulus of CELL for,,ice,Dalic
Applicant
NOTICE TO APPLICANT If.ane,making unix certificate of Emmurim,yon should
bcconm no%objecthe Workers ComPencarion provisions of the labor Code.you must
Q O form,i th'cmnPly won ohl......Inion,or Ihis permit nbJl he vicemed rooked. _
z CONSTRUCTION LENDING a A6I7NCY> 1 herby affirm that there is n comma ion lending agency for the Performance
of the work for which this pcnan is i—ned IScc.3047.Civ,C.)
Q Lendm's Name q /—
Z Isndcr's Address
U O 1 cenily nue 1 have line This applicarian sod mine Ihm the above ior"nowinn Is
4si F. coven.I ague in comply with a0 city and cmmny oNinamc,and clic laws misting
O U m Wilding conumction.and hereby authorise representatives of this city m enter upon
'y W rhe aloof-mnnmned pmleay for inspection purposes.
F 0. (We)lease to wee.Iadcnmi l'y urs ks<p harndess the Cay of Cupenlno ego net .
rA liabil'rlies.jtmi...cnas and eyemc%which may in any way same against said 36-o
a
U `
City
in c. "I of the 6mming nl tris penmir. 6/— q 6—d D
APPLICANT tN TANDSAND WILL COMPLY WITH ALL NPoINT Issued by: �j/ I�aIC
SOURCE 1( .0.ATI<NS.
Sisnumre Ui Apn"an':an me D]]ae Re-roofs
IIAG\Ril(IDS Mn'niRln LS DISCLOSURIi
Will enc apphcam r.,future building occupant,ao,in hrmdle ha anloar nlanial Type of Roof
as Jclmcd by the Cupertino Municipal Code.Chapter 9.12 and the Health and Safety
Ctrl'.Section 25532(4)?
D yes nNo— All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection. I agree to remove
to emit hara dons eir coma omams us de/fined by the Bay Area Air Quality Management
Di'vin? r_4A all new materials for inspection. Applicant understands and will comply with
EI Yes all non-point sour• regulations.
1 have read the hroa dons nmterials requirements under Chapter b.95 of the
Cul'Ihnrll is Ilenhb&SutOy Coote.Sections 25505,25537 and 25534.1 uno,stand that
ince building does a,, cumanly have a tern.dost it le any rspamihil a.u.nod l y the
neeupam of lin menus which Inner he mer poor m issnamee of a Ccnificam of
" Signature of plicant Date
All roof coverings to be Class `Be' or better r
Can"raumariac sem /
4