00030145 (2) CITY OF CUPERTINO PERMrrNo.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION::
0003014,
g—
BUILDING ADDRESS: I 57' I - _E ,(474��
z�dr� /y�eLeLLAN ��, J�JUL I//5I'/1'TIi'T � vFIJ � 'SANITARY NO. APPLICATION SUBMrRALDATI
OWNER'S NAME: /+g 176$ /V4�/O� )KZ 4610 NIC CONTROLN
yds'-,25Z A1666 &q /7s�IS D
ARCHILECL ENGINEER - BULUING PERMIT INFO
00
S7�
�{•�� I hereby afford
ma licensed
of Chapter 9(c 1. Job Description
Oc—O
F:C w with Section]000)of Division3ot Ne Business and Rofoaiom C)alcyyW myl' /
< full force and<Rat. �
o at n L d g j ez 6_0 uJ c
a�5 LL U ADatc Contrator
C O ARCHMOr'S DECLARATION
1 wasimmnd my plans"I he used as public records
K
e Co z
Licensed professional
OWNER-BUILDER DECLARATION
C Y< 1 atmos aHinn that 1 am exempt from the Contractors License Law for the
reason
C following .(genion 7031.5.Business and Pmfrasisms Code:Any city a county
i= which Requhn a permit to cwutrun,alcor,improve.dermmnlim.w rtpir my suncove Sq. Ft. Floor Area Valuation
pdorto its ismane.also requires theappli....fonuch pemat 1.filtesignedautcment N�($'98e O
Nat he is licensed pwsUth
nt to e provisions of tithe License Law LicLaw(Chapter 9 V
(commencing with Section'I000)of Division 3 rani Business and prnftuiom Cods)in N Nu r a.��
dust W is exempt Nwefmm anti the basis for the allegw eumption.Any violation a ` occupancy Type
Section]031.3 by any applicant fed a pound mbjats the applicant to a civil Farm,of 3 " D✓S
t more Nmi
en live Rini dollen($500).
p 1,as away of use property,or my employees with wages as their Role compensation. Required Inspections
will do the walk,and the mucame is an intended are offered fed We(Sec.]Om,Bu past
and Pmfessimu Gads:TM Clonescau'.License law don n coapply to m owner ed
propny who builds or ireprovo Ncrmn,and who dao such work himself or through
his own employes.Provided that such improvement are not Intended or fm:4 for
We.If.howercri the Wilding wimproveusint is sold withinoneyldorim rove far par.-Wilda
will have IM burden of proving that he did not.ye or improve rat pun
Qeofsele.).
L u owner of do,prop ty am exclusively contrmung with licensed contractors to
onswa do,des am ISR.]Des,wenT and Professions Cam i The as Cher fm's ti-
mom
Y ��
who law dors rot apply to al owner of%opcny who Wilda ar improve thereon and
License ra.for Ruch projau with acatracmdO licensed pursuant the ConBactofa
License Law. `J
I em exempt under Sec. .B d:P C for this recon VY
Ower Date
WORKER'S COMPENSATION DECLARATION O
bel healthy affluentry oat of under penally of pe juof arc fallowing dalanations40 :
Iand will mairolinaCenincucofConsentroseleinamle red worker.Compn-
uom,as provides fed by Secum 37M of the Labor Code,for the performance of the
work for which this permit is issued,
V71 have and will mlarad.Warkera Compcn lion Imme
ur ,as required by Section
]00of Ne labor Code,fa the prformaae of lle.,it for which this permit is issued.
My WortgrD So ocnsgti nsuyrcc carnia and Polity nu O�
Camcc FIV N Policy No.:
CERTIFICATE OF BXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This cation sed an becomplered ifthe pcmdm is foromhundroddol Ws($100)
in less.)
I certify that in the performance of the work for which this permit is issued,I shall
not employ my Arson in my manner so as to became subject to tic Wurgen'Compere-
satim laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
bacon¢subject to Ne Wod,m s Compensation provisions of the tabor Code,you must
foMwith comply with such provisions or this Fears shall M dammed revoked.
CONSTRUCTION LENDING AGENCY
Q p I far whifhthi Natrm bar (Sm.
30 l7. agency for sew prfonnance of
Z y ...
e walk for which this Amit u issued(Sec.709].Co.C .CJ
Laedcrs Name
ori > Landers Address
tor] 1 certify that 1 have read this application and slate Nn the above in(omnlim is
d z coarct.I agree to comply with all city and county ordinances and solid laws Relating m
Z buildingcroswctim,arta Wreby amhwle repromadiives of IN,city to anter upon the
U C above-mentioned property fed Inspection purposes.
4. t,,. (We) ,mu.nave,indemnify and keep harmless the City of Cupertino against
V liabilities,judgman.costs and expenses which fumy in my way amore against mid City
} fr: incousell mince a fine granting of Nis permit.
AYPI.IC� UNDERtirANDS. 'DWILL COMPLY WI rH AL1.NON-POINT
SOURC
615
Sign�Re i/Contranor Caft s —
HAZARDOUS MATERIALS DISCLOSURE [••/{
Will the applicant or future Wilding occupant store or handle harardaus material Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12,and the HWN sed Sa&ty Type of Roof
Code swim 25532(ily YP
❑Yes Wo
Will Ne applicant w future Wilding acupmt use equipment or devices which All roofs shall be inspected prior to any roofing material being
-mit hauNous aur conbmmand.as defined by the Bay Ana At Quality Mauagtment installed. If a roof is installed without first obtaining an inspection
°int] I agree to remove all new materials for inspection. Applicant
]Yrs %ONn
Ihave read the hasardas materWa rrgoireirmn under Chapter 6,95 of Use Cali under
mply with all non point source regulations.
RUIN S ty Code,Stearns 25505,25333 and 25534.1 understand that if thedas neatly have.te .that it is my resomibiliry m notify Ne acupdo
of Ne re4 which mu. trot prior m I am.of a Certificate o (sec cy.
`c c Signature of )cant Date
' ......tVlfDan
All roof coverings to be Class`B"or better
OFFICE