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00050084 CITY OF CUPERTINO - PERMIT NO. BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: ���� BUILDING•AD,�RES : a l/y�a/1g./�L�{��N ■ `�/�/t�.sr;`Woo dZ 1 ,AA Og'V(��(s�/G./� ] �� SANITARY NO. , APPLIC_ATIONSUBMIITALDATE ., O Nr ONE:✓I(AV•+rv'I/V-'' V J� - • VrhA—,J '" ��F'•��''—\ W — —NTROL# /�•{�11�' /^ ��yy��•(� NIC CONTROLN ION.',: - � ARCHITECLENGINEER - �/- ./�g e � BULDINGPERMITINFO 0p CV aFi6n. - H - LICENSED CONTRACTOR'S DECLARATION e 1 hrrzby effort,Net l.licensed undo provisions of Ch 9 comsroncin Z f-c w ode (commencing Job Description ` l.,y t•w ouSection]Opo)of0ivision3of du Businru ma Rofa io Codr esti mYliecnxis ae" Q in fua.lif C, and eRec ^� 5 O 6 D Lia:nae CI Lic.M Caw •3 LL DBIC ConaraCm! k i�O< ARCHITECTS DECLARATION < 1 and pl f II h uu-0as Public records n3 Q0 Licensed ro l wbki -BU ER DECLARATION < I ha' Y eRm,that I mPt Gen the Contracmrs License-taw for the D following reason(Section 703 1.5,Business and Prolesalm t Coo:Any city m county c. which rectorial a permit to consumer,alfa,improve;demolish,m repairany nunn urc S Ft. Floor Area prim 10 its ismame,also tegWre,theapplicait fmsuch permit m file a signed.teenal q' '� Valuation Nat he is licensed pursuant 10 the provisions mme Contractors License Law(CMpter 9 C7Ma�T_f (commencing with Section]000)of Division Sof N=Business and profasiaa Code)m that he is exempt therefrom and the basis for the slleged exemption.Any violation of r�� r A Number Occupancy Type Section 7031.5 by any applicant for 0 permit subjects the applicant t0 a civil Faultyof 4O© O , tea more man five hundred doll.("fflu, ❑LasownaafinepmMny.mmyemplayaswiNwagaumeiraalemmpmaau0n, Required Inspections andwill doth.work,Cosec imC misnaimendedorawdosm salapplyt sin owner , p.Prof.uiou Code:]he ove.therec License law dors nm apply us lf owner h propene who build,Pr ivided a Narcan,and who nue,such work Morrell or lhmugh ^ his own employees,e provided man such improvements.tea intended or offered for sale If.however,thebuilding orimprovement is sold within aneild rimprovle for the awe.fsam.) will have the burden of proving Nn he did not build or improve for Pur- ❑1,u comer of t, property,.exclusively convecting with licensed rmanno.m camo-La d project(Sec.7044,wormers and professions ds or iThemproves es thereon,s red a�� Cenu law cors notapplym m ower or maperry who sed p or Immo to Corton,and QTY► who connects for such projects with econauror(q licensed pursuant m the Contnaoea License am Law. . ❑lam exempt under Sec. .B,4 PCfor Nis ruson Owner Dam WORKER'S COMPENSATION DECLAIUTION 1 hereby afinn undo penalty of pe jury an of Ne following dcd.tiom: I have and will maintain a Certificate ofCouenu,self ins.for Worker's Compem section,as provided for by Seclien 3700 of the Labor Code,for the performance of the _ work for which this permit is issued. VI have and will maintain Workers Compensation Insurance,u rnluired by Section ]00 of the Labar Code,for the perfarmmce ofRc work for which Nis permit is issued. My Wocarrier and Policy n .Carrico 11 A LL•MTJ Policy No.: W CERTIFICATE OF EXEMPTION FROM WORKERS' " COMPENSATION INSURANCE , (This satin-need am becompmCW iffl a pcmtit is forces hundred doll.($100) or less.) I Candy mat in me performance of to work for which Ni=pemm is need,l shall tea employ any penon in any manner so as to become subject to the Worker=Compere- sationLaws ofCalifornia.Data - Applicant NOTICE TO APPLICANT:If,after malting Nis Genific to of Exemption,you should . become subject to the Workers Compensation provisions of dee Labor Code.you must forthwith comply wide such provisions or this permit shall be deemed invoked. CONSTRUCTION LENDING AGENCY Ihertby my.mm them is a conslmmlon lending agency farm.performance of the work for which this permit is issued(Sec.3097,Civ.C.) Lendees Name a lenders Adams - W G 1 cenify Nu I have mid Nis application and smm met the above information mi tion is r correct. ons r c comply with an city and county eminences andcute laws r upin8 ro U Z buildingconswddogmd forebyaulhonsmoses, taivn o(this city mcnar upon to ebov..(Weioned agree far inspection nsity an keepha. GL tr (We)ag e e,cull,indemnify and kap hayiinan me City of Cupertino idCtagainst V liebilitia,judgmmis.corn and expenses which they in my way accrve again-mid City ^>0 W deco ociptemeofm tin6 ofm is reit APPLICANT ER. ANOti WILL COMPLY WITH ALL NON.P INT V Z SOURC' 11I15F aNS. {�Tp ' -dA - vector Dim e_ !—•aI`�7o•L=t.:t�r I RDO MA ,RIALSDISCLOSURE Ill a.,heammfume ng occuparst,tommliamilehrzambstarnmrial Re-roofs u defied by the Cupertino Municipal Cade,Chapter 9.12,=tea the Health los Safety Code,Section 25532m)? e� Type of Roof ❑Yes Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being smith earAousaircontuninannexdefine by me Bay ArceAir Quality Mmm age =nt installed. If a roof is installed without first obtaining an inspection Dis4iC1? El Ya I agree to remove all new m terials for inspection. Applicant's I have read me heaarduus matenab requirements under un erstand '11 with non point sour r ulations. mad sta of Ila Cali- P forma HesIN ffi SafCy Cade,S lions 25305,25333 end 25334..11 urMcrstend that if the buildingdcexnp oily p Of bammeeet oNar it is my iraponresibilirymnaifyfdte woccu pul Si'gnatDateO Date V1.1 roof coverings to be Class"B"or better OFFICE