00040020CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION _ PERMIT CONTRACTOR INFORMATION: /^7-`/h1
BUILDINGADDRESS: ///��t 1 WV 60 i—
/ zU` .��)y /PI I��g+.• SANITARYNO. APPLICATIONSSUBMfITAL DATE
OW ER'S NAME: Q lIJj� 'J .. Y/e-'N-7/1 L �l . sell, 7- c.0
NIC CONTROL v
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ARCI IITECT/ENGINEER �ey /L.y IIULDING I'ERMY1 INFO
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Z O ,"„ z LICENSED CONTRACTOR'S DECLARATION
O Z _ I leateby .Rrn to 1 on licenmd under provisions of Chapter 9 (commehe -9 Job Description
F:F'� with Saban T000)orDivixion3ofOS Bu.innrWPmfmiona Cede. andmyliana i. ,
�K�G in full force and All
IJmarro Clare C Lic.g
t g O gARCHITECTS DECLARA ON
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undentm4 my plane Thad W anti As public records
a o LicrosN Irmfeesimusi
- aI OWNER -BUILDER DECLARATION
C >' 1 hereby affiml TNI I Am exempt from to Contra oVs License Law for the
i 5 m following Tosses. (SAction 7031.5. Business end Professions Code: Any city or county
oc which eequha A permit 0 contract, star, improve, desaxiah, or repair any g=ntm Sq. FL Floor Area Valuation
prior to its immam, elm tegum the applicant for ouch permit to file a signed oetement �<-'I�,G-
thathei. Ilcenetl punmm rothe povioians of lla ConauTof, License Lew lCTaper9 c..% V
(..A.cingwiths«gnnT1100)arol.imalmrtneee.inwanal+orermn.cMejae ane ppN Number _ Occu Type
t o he is exempt therefrom and the Buis for the alleged eumpaon. Any viola ion of P Y YP
Section 7031.5 by any Applicant for a permit mbjects rhe applicant to a civil pext, of 3G G
not more than five hundred dollen 0500).
❑ Le.aw erarth<proP rr.«my mployn.withw,gnmth irwle amp intim. Required Inspections
will do the work, and the.mcwrc is ora sanded a oRemd fa We(S«.70/6. Buunn. ,
and Pmfeasion Cede: Ibe Connector's Lt... Law does are apply to An . or
property who bullae or videdvt thereon, nal who don ouch wok deed m f through
his own employees, provided to such mentos sold
on ora intended a offered for
rete. If, however ,thebuildingurimprovement hsold withinoneyaraf prove No will have the burden of proving Net ha aid not build or improve fa pW-
pouafule.).
I, As uthe p of the San 7 property, on Business exclusively conoActing with Ilttned emmunts .
onmumtheproject (Sas. An am,ofand.1Wiom Code:) The Cantnetd. U. T
whoa law dao trot apply to ts owner of propertyora mho hills cr improva thereon, and
whence La tx for such pmjecu wish a conmaor(el lketued pursuant to the e00aActhr.
Llano law. .^
I am exempt under, Sot. . B $ P C forth rea+on ,
Owns Data
WORKER'S COMPENSATION DECLARATION
I hereby affirmunder penalty of perjury one of Ne following dcclmmions:
1 have Ana will minuin eCenificate ofCouem m ul6inwrt for Wmker'eCompen-
cation. as mviM for by Section 37M of the Labor Cade, for the peoNonssee of the
work for which Nis permit is ismed.
❑ 1 have and will maintain Worker, Compensolon Insurance, n minuted by Sorties
37(pof the lobo CMA, for the performance of Ne work for which thio permit is irnd.
My W '. Com eUn i In u Po d Picy NI'�ocy �uplks -91 ice'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This eecsim nod rotb<completed iftN pewit is form hundred dollars ($100)
or leu.)
1certify Out in the Performance of to work for which this IKr it is isaued, l shill
not employ any penin in my thenar An as to hcome susacno the Worker' Camper.
Action laws of California, Data
Applicant
NOTICE TO APPLICANT. If, Afro molting Ni. Coni&as of Exemption, you should
hcom mbj«t to the Work T. Compensation provision, of to Lehr CMA, you most
forthwith comply with such provisions or this permit oNII be darned revoked.
CONSTRUCTION LENDING AGENCY
Q I hereby omen to there iota const.W. sndingageny Not, perfo.A.1'
to work for which this permit is issued (Sot. 3091, Civ. C.)
F.t r Lander. Nome
C4 > larders Address
W Q 1 certify Out 1 have had this application and one that to above infomudon is
A coet. I egre<to comply with ml city and county ordinances and %me laws relating to
.7 z mbuilding cWoraction, AM Wrathy mthoda representatives of this city theater upon to °
V 0 above-mentioned property for Imprstion purposes.
W Fa (We) gree to ave. indemnify and keep houlea No City of Cupertino against
C fj liabilities, judgments, costa and expenses which my in my way Accrue again rid City
y. W in consequence of the granting of duomit.
y APPLICANTUNOER 'ANDS WILLCO LYWITHALLNON-POINT
t.i SOURCE RP NS.
y -s- oo D�
51 rare of pplicandcon toe Due i
HAZARDOUS MATERIALS DISCLOSURE
Will On applicant or future building acupentocre a handle Nmdou3 material Re -roofs
as defined by the Cupertino Mut id,l Cede. chapter 9.11, and the HW th oM Safety
CMc, Section 15537(a)n Type of Roof
❑Yea Btfr .
Will IN applicant or future Wilding mrupanl use equipment or device, which All roofs shall be inspected prior to any roofing material being
emit hetatdou, air comaminnu u dented by the Bey Ara Ah Quality Maraparent installed. If a roof is Installed without first obtaining an inspection
°"""'
❑Yn I a ree to remove all new materials for inspection. Applicant
l� •
hoe n,d Initial.,m.ariWrg;amhnaandLm.pmA.95afth Gai understands and will comply with all non point source regulations.
fans Health h Safety Cede, Sections 15505, 25533 and 25536.1 understand tNt if the '
Wilding does not cutmtnl have A wham, tau It is A, responsibility th notify the ecaprt
of oir�nletype(t0 lean'". ore C<nificakn Oce .
��Signature of Applicant' Date
Owner or nzM agent Dak
All roof coverings to be Class `B" or better
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