00020036 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0 O-'0 2 010 3 Cp
BUILDINGORE55: Gf/fIJ�E' �/E.y77a2� /VL'. �& j"
22
S /,r //I1//j {fin/ /,yry'/ SANITARY NO. APPLIC ION SU MITTALDATE
O NE NAME: CY� 'vU O//G!N /J[��• NIC CONTROLse
ARCFIITECfASNGINF.ER `�j!/J 29'3 /�//2 BULUING PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
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I thereby affirm
Net L am licensed tide,Provisions ons or Charmer mar9
y� f2i� Jo0b/Description
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K,t:w wis«tionT0 )ofDivision3ofeB.sinasandPfcviamco .aadmyli«n
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ARCHITECTS DECLARATION
v�so-, I undenstae my plans shall boosted!as public sectors
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a S c Licen.vd ProheaaiorW
w. OWNER-BUILDER DECLARATION
(_ r 1 hereby affirm the.1 em exam,,from On Contractor's Liame,Law for the
Z O following meson.(Section 7031.5.Business and Professions Code:Any city m county
iC m which ref era a permit m com act.tor,improve,demolish,or repair my stmemm -
3_ priormnsissumer,9.scrolls Ona E...Ifmmcnpermit tofit.simadiumment Sq. Ft. Floor Area Valu/"](Ion
that heislicmsed purposes m On provisions of the Contr«tors License law(Clum«9 y C/
(commencing with Secum7X(Bol Division 3 of On Bud.and!Prefevimu Codr)m APN Number
Wt he is almost therefrom a.d the basis for Noccupancy e alleged ascription.Any violation of _ o / pa Y Type
Section T03IS by my applicant for a pound,subjects.he,appliwu to a civil puWry of
r.w mom Nm rive hundred dollars(5500).
C l,wr cotta,ofOnproperty.ormyamployeawith O,l as their me compensation. Required Inspections
will do Na work,and lieawaum is ret imeMcd muttered for Onto(Set 7000,Rumania
and professions Code:The Comm ors License law does not apply o an owner of
propepropertyopy who Wilda or improve..hemnn,and who dna such wank himself«though
his own employees,Provide But such improvements ase nm inmeee lir ottcmd for
We.If.however.On Wilding of improvement is old within rise year of rnn.pWion,are
comser,1xidder will Masa the W.den of proving Net he did not Wild m improve for par-
prose,
r- `�
pose 1.
areal s�`rl
C 1,v ow«c of the impart,am caclusively imnrtacting wish license contractors to ��
construct the project IS«.Vtaa,Business"Professions Code;)Tho Contractors V-
cese law does Out apply o an liana of proper,w W builds m improves Nercon,and Q
who contacts for such projects with acomm�or(a)licenced ur s
pummkto the Contracto
License law. 0
C 1 unwire,under See .B&P C for Nis ruin
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pensly of perjury ore of the following d«Dmtiona:
C Lhasa W will for by
tion 37W of the Loan
selfkeno"for Workers Co of th
tinn..a provided ran br s«tina non or the sabre code,for me pe.rm,mn<e or me rw r which Nil permit is issue.
w have and will maintain Worener Compensation Insurance,as mquirad by Section
3900 of the Lobo,Code,for the performance of the work for which Nis F«rift is issued.
My Wllc-s�ypenyii a ce certier and Polley rumba,lett__I�i 9
Cssd«. I[ IVs-Policy lacy K.l[IY))
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nee as be com latedihtha Famous is faro«hurried dollars($100)
o.it..)
I emsify Our in the Ndmoss.of the wank for which Nis permit is issue,I shall
but employ my Arson in my reenter o v to became subject m Na Wmhem•Compen-
sation laws of California.Data
Applicant
NOTICE TO APPLICAM':If,after making this c enificam of Exemption,you should
become subject to the Wodur,s Compensation provisions of the Labor Code.you mum
forthwith comply with such povlsiors or this permit shall bu do m i invoked.
CONMUCDON LENDING AGENCY
Q O I hereby ern that Nem is a consto<aon leading agency far On pe.romunce of
Z the wank for which thu permit is issue(Sec.3)97.Civ,C.)
Under,Name
} Lenders Address
(z] L certify Net 1 have rtad Nis appliotim and two Out above ilii mu.tioa is
Qo G correct.l agree to comply with all city and county ore irunca and state laws minting in
Z buildingconstruction.and hereby smhorim rcM.Ornalwal of this dry o enmr upon On
C.) O abuve.mentiond protan,for inspection purposes.
is., L,, (We)agree to save,indemnify W keep haemlas the City of Culenino agelmt
0 U IlaMlitics,jud,..U.smmaad eapeay.which may in my wry«cane against via City
}
Win crosegoe..ce,of lie&.on,of Nis yamdt.
[•^ Q- AYPLICAM'UNDERSTANDS AND WILL COMPLY WI III ALL NON-POINT
C.) Z SOURCE RE(UTATIONS. /
Signeto.ofe UCommmm
AZARDOUS MATERIALS DISCLOSURE
wrath app' .marfmnm budamg ocenvmt mart nr treadle naaWnnamamn.l Re-roofs
as def aced by ii,muo Municipal Cdr,Chapin,9.13,and Nc Naa1N and Safety Type of Roof
Code.Section 2353200? IN YP
CYes n
Will the applicant lir house Wilding occupant use cquipmem or devices which All roofs shall be inspected prior to any roofing material being
ami,hmudous.ir<muminmb m defined by the Bey Are Air Quality Mmagemen. installed. If a roof is Installed without first obtaining an inspection
District? L-Y^// I a ree to remove all new materials for inspection. Applicant
C Yel
Ilove mad On harudous marinas mgWmmmm under Chapter.695 of the Cali- understands and AI comply with all non point source regulations.
moi Halth&Safety Code.Section"o"]3505.25533 and2553x.I undimrandready
O out if the
Wilding m urmm
ngdnm ctlyN emount.Nriit is my responsibility orice,arrc rrtcupmt /
of Or mr,momeas which m mo umance of a Car.ocam of
Signature of Applicant Date
_ Owner or auawnzda t a�—
All roof coverings to be Class"B"or better
OFFICE