00030132 (2) CITY OF CUPERTINO PERMITNo.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: D00310137—
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ARCHITECT/ENGINEER I BULDING PERMIT INFO
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I.. LICENSED CONTRACTOR'S DECLARATION
o o= c I hertbY aRw mu 1 w littnscd oda aovisiom of Chapter 9lmnttrcneing Job Description
<---WI with Section]Odeffect v'sion3 at Buaimu tad Pmfrssiau Code,edmy limmeis
aye_ L full force sd eReet 9, /r/J /.1- �'///1 �,//0 l / 4dkl
pw U IJmnu Cl Lie /f��/N.V� ✓ `� e //�•f'f�
Dam Conumor
Fin..u3j O gARCHITECTS DECLARATIO
F 1 undenwd my plans shill W used u public records
KrQ
i:S:ff LicmaM professional
N R a OWNER-BUB.DEfr DECLARATION
�_>.n 1 thereby,(Sero on 1 w exempt from Ne Conermlor6 License Lew for Jn
F❑ followingch er sentence,(Section 703 1.5,Business eM Re,ch ions Cate:Any city a Canty
C which rtquims a pnmil to construct,alter,improve,dcmoliN,or rtptir my ewcture S FI. Floor Area LIat�Ij
a3�
'nor to its issuance,ilx regains theapplicent for suchpwdu-fleesigrtd sutemem q' C/ (//jV/'
that he is licensed armat to the provisions of the Counselors License Law(Chapter 9
(commencing with Section 7M)of Division 3 of the Business and Frofeulma Code)in APN Number occas Type
,ut he is exam,therefrom sons,Cc basis fa the alleged exemption.Any violudon of occupancy YP
Sectio-7031.5 by any mduart fa•panda mbjrcu the applicant to a civil pealty of
rot morewn rve hundred d-Bux nS00).
❑1,as-wner-foe,progeny,m my employees with wage o their role mmpenation, Required Inspections
willdoshcwak,ad de,awctun is nm intededaoRrnd fm Tek(Ser.]Oaf,Busiaca
and Pmfessiom Code:The Contactoh Liana law docs ria apply to an owner of
prom
py who builds or improves thrower,end who does such wort himself a le through
his......loyees,provided that such improvements sure not intended in-Herd for
ale,If, ilder withebuildingune.of prmem lesold within one ywof completion,the
r-Wilder will have Cc Widen of proving met he did nal Wild or improve for pur-
cose
I,u Gower of the property.w exclusively contracting with Ikenad cmtranon to ^y�/-/vU�—I�/
cmewa the ce ou, (Sm.]OCC,Business.o "d prolamines,Cdr:)The Contterea.Li. /„ `"] //� j
ime,LawwW artr does r soil, i an wish
-of proper who Wilds r at in the Cert--.ad (� ///v/
who se Law.forw<hpr-jau withaconttmmggIkensd pursuer tp the C-nbmtod
License Law.
I w exempt under ga. .B A P C for this tom
\ Gwna DarePINALED
WORKF.R'g COMPENSATION DECLARATION
1 hereby affirm under penalty of pmjory ax of the following dmlwuan:
Ihave ad will maintain a Cenifican of Coaenuo self-Csum for workers Compm. JUN ry L,SOo�
atim,as provided ee
for by Stlm 3100 of the Labor Cade,fee the pctfomwa of the IY /
VI
which Cis permit is issned.
wo 1 have and will maintain Wnrtds Compeoustia Insurance,u required by Satins
3700of the Labor Code,for the performmc,of the wort for which this permit is issued. BUILDING
My W. . f par ninwrancecarrier and Policy nlypbcr.y{ J'vl r
Cunec YY// Pubs,No.:2f1{K� O
CERTIFICATE OF E%EMPTTON FROM WORKERS'
COMPENSATION INSURANCE
(This>mim need no he completed if the pcnrui is fame,hundred dollen($100)
or lass.)
I certify that in the penfornmer of Ce work for which this permit is iseaA I shall
not employ any person in any...at so as 1.brcome-bjeet to the Woken'Compen-
sation Laws of California.D.
Applwmt
NOTICE'IO APPLICANT:If.after making Cis Cenifinu of Exemption,you should
heco a subject to the wodurs Compenation provisions of the Labor Code,you must
forthwith comply wiC such pr-visions or this permit atoll o deemed revoked.
CONSTRUCTION LENDING AGENCY
QIhereby uflon that Nes is a construction lending agency for pert-ntwa of
Z the work for which this parmit is issud(See.3097,Civ,C.)
Lenders Noe
latera Address
R71 certify that I have read due application et sate Jus Ju move infomudm is
G. 17correct.I agree to comply with city and county ordlruncea adwe skws rehi 1.Z grth elWilding construction.at hereby solaria representatives of this city to enter upon Rx
"Wive-mrmlmd proper for inspection purposes.
(L F. (We)agree to save,indemnify end keep humlexs Ce City of Cupertino against .
limilaes,judgments,meta ad<a,c.which mq in my way accrue egainst said City
>m rig) in conwqueae of the grating of this fiction
r ILI APPLICANT UNDERSTANDS AND WILT,COMPLY WrI'H ALL NON-POINT
SOURC^F.NF;GULA' (lNg. l /�/� r t I
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Sig..cfA Iicm irantor Jot
HAZA US MATERIALS DISCLOSURE
Will the app cure Wilding acupent store or hatle hauerdws ro enil Re-roofs .
as dcfind by the Cupertino Municipal Code,Chapter 9.12,at the Health at Safety Type Of ROOF
Code.Section25532(e)] ,/ YP
❑Yes [Y
\11 Will the applicantorfuture Wilding oaapmt one equipment or devices which All roofs shall be inspected prior to any roofing material being
't hanrdms stir conamitants as deEad by ms Bay Area An as t,Mmegement installed. If a roof is Installed without 'first obtaining an inspection
anti" I agree to remove all new materials for inspection. Applicant
❑Ycs
Ihair nedthehuardmsmaknal,req-irement,ate,Chaprerh91 of the Cali- understands and will comply with all non point source regulations.
fmtia Ha,dR,k Safe,Code.Satins 25505,25533 tad MM.I udentual that if die
h ilrangdas rot currently love a train.that it is my responsibility to notify the necupmt
of IW retuarmmu ,.h must be apdw to iii..ofa Cmificau of 5p SSGGtI
f�.0 /- Signatur of A licant Date
Owner r,u deg - Daef
All roof coverings to be Class`B"or better
OFFICE