00030154 CI' OF CUPERTINO . PERNIUN0.
BUILDING DIVISION . ; PERMIT. CONTRACTOR INFORMATION: 0003 ,O 15L/
BUILDING ADDRESS: .1 - `
1^T - �q�t SANITARYNO.: , AP ICA IONSUBMITTALDATE
\� (5WNER'S NAME:
\ 4r •� . ,.7 01- S i,Qq.Nom^/•�+'I'' Q�y,. _NIC CONTROL#
ARCHITF,C'VENGINEER - qv O --L,6c,, — Z G Q HOLDING PERMIT INFO
EF L •' aLICENSEDCOMRACTORSDECLARADON , ' . . F• r. 'r 1 .
I hereby aRrm that 1 w licensed under previsions or chaptar 9(mmtrcae a Job Description
pZtO with Section]000)orDmntonSof die Business and lRahommens Cade,and my license I.
Tj
in fullforce n
C,:.d eB<m/JCK
ce
atan.e cl. Lie# .45GO,L'4 ..��
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w 3 w S-3.1�QD Cmuca mr Z2 &4
F O ARCHITECTS DECLARATION
E g I undentard'my plansshall W used as public mcad.
O Licensed Professional • ' - - "r t w
OWNER-BUILDER DECLARATION •
Thereby affirm that 1 am eaempr from the Contractors License Law for the I j
E following mason.(Section 7031.5.Business and Rofesaiau Code:Any city or rouniy -
to C which 'rat mail w c s t.cher,ins ve.dmadim,or an rwrnue
a °q4' °x for remain y Sq. Ft. Floor Area Valua[i
_ pdormiwcomed pursuing
me theapplinnt for such Cmdemwil micense aw(atammem _ -
Nm he is hmnwith SM1 lit m Ne pf Division 3 of the Business
ratm'a License Law(Chapter r
that he I,mmaptth da.add)me, iaitor of meegdn<aanw..a A.,violation
of 'APN'Number' _ -O cu ane TI e ,.
Nil Samoa is eaempr therefrom and dm breis for Ne alleged exemption.Any l food ly of t p Y •J P ,
nt .7011.5 by hundred canto ($5W),it subjects the epplicmuoacivil perWry of
' t mom Nan Bvc hundred dollus(55001.
1 as owd�of the pr.peny,m my empinyen with wqn oris 1 pe vw Required Inspections �N
will do Nanwn m
Ne workd Ne aaurc dI immahm offered for We 044
(See] Bi e r ` ^
and Professions Code The Contractor s Limme,law does not apply to an owner of 'f'
progeny who builds or wpmvn mmarn,and who dues such vark,himself or through
his own employees,provided that such impmvememu.nom intended or offsred for
sale.IL however the Wilding in u sold within mons yerafcompledoq Jia
cram-Wilder will have dm buNan of provin6 that he did no,Wild.,improve for Pur-
Pmeofsaf - 1 r • -
❑L as owner of rte
Property,
mperty, exclusively co'ntradnwith licensed contractors to
consumer Nepojen(Se. o.Business and Profession,Cede:)no Contractor's LL
came lawduesroeapplyoadownsofproperty �•t f- -
,
wed Wilds or impr.va then:on,esM ' ,
Licence
for such projata with aconorumr(x)IicenaM pursuanlm Ne Canhacmts t
License Law.
•' ' -
IamesemptunderSm. ) BkPCfar Nis meson' - -
Owner Data
WORKER S COMPENSATION DECLARATION
IhercbY a(Rrm der penahj.f perjury om ofho fallowing declanimus
J(have end will an midnaComficata ofc....In selGinwm fmworkefa Comped
anion,u provided for bysadon 3]00 of Ne Labor Cope,for the performance of the - ''r '
work for which this permit is issued
O 1 have and will maintain Works,',Ciddloamid Insurance;as required by Section -
37W.fthelabdCoils,For the tefonnmca.ftho work for which Chia permit is ieaued. - _ _
• My Workei s CynP se�i�n hmunn�ee cartiq and Policy number -
'
CERTIFICATEOF AFION1I NFROM WORKERS' "
' `COMPENSSATION INSURANCE•
(This sati.nneed nm be completed if the prrmia is lorormhundrml dollda(51 W) r. • -
I certify that in the performance of the weak fa which his permit is Found,l shill t '
wit employ any person in any mmrom m on m Wcmoe subjaeso the Worsen'Compen-.
an..Laws of California.Dam t-
late' - r*•
sub
t to the NT:lit after making Nis vis)n s a(of Enempuo d you should . " -
become subject b the Wohels C.mpenvtion provisions of the Labor Cade,you tun
(oMwiN mmplY with such provisions or this permit s1m116edeetrcA evoked. t - -
CONSTRUCTION LENDING AGENCY' a(: 's
0 p IhercbYdhrmeNemisacomllm ding agency fonhepMunvnce of i ...
- Z � the work for which Niss permit isissued(So'
3W7,
09].Civ.CJ'
Lends/s Norm
a > Landers Address - - g •
W Q 1 certify that 1 it<with
flus pplicaou and tme Net the Wee.ralmu
I1 coned 1 agree to comely with ell try and county oNine cee and tat lawx rclui B t {
U 0 building conswedon.mdhe bye N du mpreae w nolth's any o.toter opo dm { I ' 'a�r� •i1 /t 2000
gev
- eb.vemcmioned prony for spau rym
pues .. IVT' „M1 K /i z
4s• Fa (We)agree to save,indemnify and kap harmieu the City of Cupertino against + '3
�) liabilities,judgments,cmmmi npenses which my in any way acme signs nstsaid City
,y W in omm,.tde of Ne Bmnun dux pefmit.
,�•'+.� API•IICAN I UNUERS'fA 'ANU WILLCOMPLY WITHAILNUNdYIINT IOJt}
SUURCH RECULATIO )
uz yy
Slgnamrfo. ApplC/ican'VOom_ncto�r Dow
F HAPARDQUS MATERIALS DISCLOSURE ' , y
Will Roe applicant or future building rKcupant store or handle humorous material Re-roofs
as defined by the Cupenino Municipal Code.Chaptm 9.12•and Ne Health and Sday
cede.Section trPB2(o Type of Roof -
0Yea - ON. n
WillNeapI.artorfutureWildingmrapinuse moipmentordevia,.whien All roofs shall be,ins peetedpriortoanyyroofingmateriat:being;'
F hasudonair mntaminmuas defined by the Bay Area Air Quality Management, 'installed.'If a roofinstalled without first'obtaming an inspection,
"DYa ON. 1 agree to remove all=new materials for inspection. Applicant
IwxemarNena>tad.aamatewarc9aimmmtsunder npter6,95arN Gdi- understand ill comply with all non point source regulations:
forma Health At Safety CMe,Sections 235(15,25533 and 25534.I understand that if the
' M1uildingtluesna durtrn
mly have a me t.Not his my msponsibilk,m daily the uep
mmr
` of the rcquunments wwtacat m t .1 to msuana of.cenificue of aeupmcy. 'I '
L• i0'� ?—'�••ki/— y S t ature of Applicant Date '
Uiveri rauthunsed r t Date ' I .
All roof covering's to be Class"B'7or better,''
„ OFFICE