00040168/ PITY OF CUPERTINO � PERMITNO,
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: OoG-I 0/&
29
BUILDING ADDRESS: yyy//f n
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LICENSED CONTRACT'OR'S DECLARATION
T he,eby,Tim OK I sin licensee endo pmnsinm of e n pier 9 t�eaains /� Job Description
Fa.=C to with Session]000)ofDivision3ofreBusiness nM Pa oe(de. royliermeis (/s ��DO
oc y r in full fact and<Recl. _ pl / (/!1 C /C..K/
u .IJuau Cla�}' Lis.N / e
u�3 u N Da¢—TConvecwr ti— 'C co (S/1Q �V
p; ARCHITECTS DECLARATION �x S
z a 1 undersand my plans shall be used as public moods ^ � 1 _ 14,-4sX
..F.. ,ey
w C Licensed Ptnfmlo
eml .
OwNEA BURDER DECLARATION 1c,60
(O
1 hereby aBom on I am.Bumps from IN Coauacmrt License law for IN V
pO following moon.(Section]031.3.Business and ova.do ons Code:Any city s caumy
u.3» which requirts a .it w caaWct.Atn,improve,detmliN,or repair any sbuctwe Sq. Ft. Floor Area lace on
prim to its issuance,Asa exports IN applicant for such permit to rile a signed suument /r /)��/ G�
Nat he is licemedurs
pursuant to rhe provisions of the Conauto/s license Law(Chapeer 9 (/(/
Oat he isexewithg«dnoiandiO Wrii9for me al�miness Won An iameode)or pN Nu 1111,,,,X�j OccupancyT e
Net he it exempt s therefrom and the burs for bj .the exemption Any violation of �V YP
Semian 9W o by se,applicant
coil for a Rmtis mbjam the applicant to a civil Rmlry of
m mmre Nan rive hundred dollars y employees
. I.unwmrk.the proarty,mmYm intended
oiNw.gesaNe(See compensation. Required Inspections
wiR doldr,work,and t:noConisomimcrcdndmofferedfa rale(SIL.oan owner
aro Rty who
Cade:Thc os.dear',License taw docs nor apply us an owner h
property who Wilda pr improve,thsuch imd coed Edea such woo himself of through
Ont own employees.provided Nat such impnry sold w arc nal inuMod a offered for
We.1Lhoweverthe llhbuildingorien of
ant is soldwithinone yvre intmoufee,the
o rW e.).will have the burden of provint Oat N did net Wild a intpmve fad pw
couruct the
D I.u owtor of the propttsY,am eaolmively Ommacdng with fice0sed cano-aeas to
Occur a the eroded(SaJ(u6,Busowner
of,and property
who professions Code)The m there Connector's Lid
Occur law dos Out apply je an with
ar of erenne who Wilds m improves thereon,and
who c.Lace for-ch projecu with mantrutar(a)licensed pursuant w the Comrseuts
G hoz exe.
aw
❑I am exempt under Sec. .B k P C for Nis reason
Owner Dau
WORKF,R'S COMPENSATION DECLAMTION
sa
1 hereby slum under penalty of pe jury cote of the following declamations:
1 have and will mainuin a Cmificem of Conant to self-insure for,wmkeescompen-
Must.as provided for by Section 3700 of me Labor Code,for the performance of she
for which this Foods is issued.
T neve and will maintain Workets Compensation Insurance.u"irtd by Section
3700 of the La W,Cod,for the performance of the work for which Nis permit is issued.
My Wok9{s�p�Rema3 epiar,�-,n�A/{Pn lmy nu
curie:Cf ME�'>lNu"'w"'v Nn.: -DD 23.Y7 d
CER71MCAM OF EKEMP'NON FROM WORKERS'
COMPENSATION INSURANCE
(This account r dnIX becomPlmdif Nc permit is fororc hundred dollars(SIM)
or loo.)
I reni(y WI in Ne Rrfor c of the work for which this penes is issued,)shall
rot employ any person in any mantur so u to become subject to the Worlon'Compan-
setion Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL afar making this Certificate of Exemption,you should
become subject no the Wokees Compensation provisions of the Lebon Code,you muss
forthwith comply with such provisions or this permit shall be deemed rtruked.
CONSTRUCTION LENDING AGENCY
O 0 Th ere by aRrmspersoni iaa ed(Sec.3097.Civ,agrncy fonN aeom„me of
z 4 Ne wwk Be whish this psoas is issued(SIL.3094,Civ.CJ
Letker,Name
�i E lander s Address
ry) I certify Out I have feed itis,mrw,om and situ con she son,l cos s h0m,i,
P4 Q building U.se comply with ell city my emmry ordinances and sum laws¢haring he
7_ Wildinesmawcdon,Whereby
orinspctionurpose, utives o(Wscityto ancon upon the
V O aWve-(We) d
property for inspection purposea.
C F (We)agrrc w ave,red es,a end kceF harmless the city of Cupertino,saidboost
City O C7 lubilities.jdgmenh.cauand es Our re
which mvy in any cosy acerae¢gems oda City
^�. M- inconse9 NT Ndte Brainingof Nis pem,it.
F a AI'PLICAOT UNUERStANUSAND WILL COMPLY WI'T'H ALL NON-Y(IINT
LOSOU RCE RFGULATIO.
S,nomm,of Appli enr/Cnnvnm Dau
FIA7ARDOU MATERIALS DISCLOSURE
Willthn.,iic Wildingorcupnmstoteorhandlehacesks-mammal Re-roofs
m defmd by the Cupertino Monde I Code.Chapter 9.12,ad the Heddt road Safety T e of Roof
Cods,Section 255320)4 YP
❑Yes No
Will the applicant or future building cocupant me ecoymem or devices which All roofs shall be inspected prior to an roofing material being
mall hauNous air aunovoimnu a efned by the Bay Arca AO Quality Menagcmem installed. If a roof is Installed without first obtaining an inspection
'tries? I a ree to remove all new materials for inspection. Applicant
❑Yes
Ihave mat,the bamOuus materials ro,uiamenu ander Chapter 6.95 of the Ui un erstands and will comply with all non point source regulations.
tuna HUIes s:Safety Code.Sections 233113.25333 and ns336.I undvsund TNI if rm I V 411-7),110
/�////)
foreasbuildingdcean Stress,Ccdx VS aButte,ViS15,decoy rtsdo 53OI.1ility so under nerst occupant /I/V
of doemenmuss be a priorto issuance itic c �Ike of 0 Cenp Y
�l�_u mUSignature of A licanl Date
Owner ar ere zed¢gen Ueu ,
All roof coverings to be Class"B"or better
OFFICE