00030016 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT
O W C/ON.�T�RACTO/R INFORMATION: O DQ 3 DD I
BUl1YADDRS SANITARYNO. APL ��/ �pN
U AL DATI
N � /7fy / d/ 4 _11 { /1"•
NIC C0Y7AOLp
hdd
56 9�!/ 1o7y1 1�lu�GUai'd, Co' 4/ysf's/�l ❑
dCHITECn1iNGLYEER s/G'Zy✓ "l`"�r� BULDING PERMIT INFO r
OC
U
Nz.w
F j-ce LIC Our I a limrRACIOR'S DEdimi N C cep
a o�1 I hereby aRrm than 1 am licensed seder provisions of Chapter 9(c 'ng Job Description
ode—o
ySw with Section]OW)orDivJJ'sion fides Business anti Rofevi.wC ad my � �
; in dell force and eRect.Lrr��.t /l(/�`j�p ��� l in`j� lie
10=u ueeme Clan LL'( Lic.x ((//11//L� (i/ 7(/JJ G/ / (-(/�
3 a u Dam Commacror
F-u.0 ARCHITECTS DECLARATION
S 1 undenmd my plana shall h used a public rads
to
K
az Li<rnred ProrevioaW
n u'vj^N
OWNER-BUILDER DECLARATION
C Z a 1 hereby.Diem than I..exempt mxempn from he Canon,Coe License Law for Ne
wZ O following moon.(Section 0onstru Business and Pro(demom Cede:My city s smarmy
s—= which nquim a permit m construct,alter,improve.dcnmliN,or npeu any I.unwe S Ft. Floor Area V uatioq
prior o its iuwnce,also requires the applicant for such permit m file a signd rmmmem q' / (� //i]
Out he is licensed pursuant in the provisions of the Con"mtora License Law(Chapter 9 / t/(/
(commencing with Section 7000).(Division Sof the But ad Frofeuimen Ceditp Number n Occupancy YP Type
Out he is exempt therefrom and the hues for the alleged exemption.Any violation Or n //'
Section 7031.5 by any applicant fa apcmill.bjecm the applicant to re civil piWry of 3
pt mote then five Wdred dollars(3500).
1,as owner oflhe propenY•nmy cmployeca wile wagnurheir sole compewtiw, Required Inspections
will do the work,and the Infamous is not luded in offered forsde(Sm.7066.Business
and Profudou Cde:) Com 's e mLicense law does not apply to an owner of
property who builds or eminates therein,and coed does such work himself Or through
his awn employees,provided that such improvements am ON intended m offered for
tile.IL however the building or impmvemem is sold within one year orcompletion,the
ower-builder will have the burden of proving Net he did nee Wild n improve for pn-
youofsde.).
❑1,in Owner of the prnpe ny,ON exclusively convecting with licensed conmacton to
concoct Ne project(Sec.7W,Business and Professions CWC:)The Committees Li.
cense law docs nth apply to an owner Of property who Wilds N improves thereon,and
who conmacts for such projects wide a coneracdN(a)licensed pursuant in de Conuactor t
Licrose law. /
I am exempt under Sm. .B @ P C for Nis reason
Owner Deck ^
WORKER'S COMPENSATION DECLARATION V/
1 hereby w affirm oder rerWtY.f pdjoY On of the 1. Iftue
Labor
Code.for des ref.Wemia Conflict.-
.am.
ompere I"1
tion.as provided(a by Section 3100 Of Nc Lebon Cede,for the pertommnee of the
which Nis permit is issuedad will maintain Workers Comprnwion Insurance.u requirtd by Section
1.14k ,
NoyWmkc{s,C �ppe,�y jxtncc<articrandPolicynmartiml /(� Y/�/lY/ Policy No.:CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This section tamed nm W computed ifthe permit is formic hudrm dollen($IN)
r len.)
I certify,But in the puff.,of the work for which Nie permit is issued,l shall
not employ any prion in any manner an as to bemoan.object to Ne W'oharY COmpen-
.time Laws of Cdifomia.Dam
Applicant
NODCE TO APPLICANT:IL after making this Certificate of Exemption,you should
hmotne subject to the WNkces cN apieaSat100 pmvanNi Of Ibe LOW,code.You man
forthwith comply wird such provisions or this permit Nall W domed molted.
i
CONSTRUCTION LENDING AGENCY
Q Q Ihemby elhrm due then is a construction lending agency fn the performance of
z Ne work few which this permit is issued(Sm.3197,Cie Q
Fou Landers Name
a , lander;Addmxs
6r7 1 unify nhar 1 have mad this application and awe Net NC above infomutioe is
G. zcart.I agree to comply with all city ad county ordirweesd aseem mlafio
m laws ng
z building construction.and hemby aoherrice representatives ofdlds tiny in error upon On
U 0 e "u.nma band property for inspection purposes.
IY t" (We)agree he uve,indmmnify and kecP hamsleas the City of Cupertino against
U habildix.Idguane,moats ad expenses which may in my way amoe against said City
�., W in comequcumM a goi of this permit. `
wFwa APPLICANT U II SIANDSA IA WILL COMPLY WITH AI.I.NON-Pf)1NT
U z SOURCE REG IDNS. � f��
Sigmene.of Appy Nx3tac p D / �^
ARGOLIS MATERIALS DISCLOSURE
Will the applicant or future Wilding omupam store N handle haradmo material Re-roofs
in defined by the Cupertino Municipal Code.Charger 9.12,ad dee Bonito and Safety Type of Roof
Code,Sexism ss532(all // yP
❑Yea YNO
well the"dicam Or fu"re Wilding accursed..equipnnmor deices wM1ich All roofs shall be inspected prior to an roofing material being.
emit lnman..aab<mmemiemnts u defined by dee Bay Area Ab Quality Management installed. If a roof is installed without Irst obtaining an inspection
xvnl I a gee to remove all new materials for inspection. Applicant
❑Yes []AO gg
(have read de lmaaNws roods ropon amd"udn Chapter 6u5 of ere Cali. Linderstm s and w• 1 comply with all non point source regulations.
(anti Health S Sd y Code.Sectio.25503,23333 W 25536.1 udetsud then if rhe /J J
building does ern c heves"num ithmY reeponsibiliny to naifY the Ncupant (/
of the reyuvcn n h� mono(the n man he "."a.._ Of a Cmilicam r�m"avaame Of a Cmilicam r�m
Signature Icant Date
rewner.r.. ort
All roof coverings to be Class"B"or better
OFFICE