00030136 CITY OF CUPERTINO PERMITNO.
f BUILDING DIVISION• PERMIT CONTRACTOR INFORMATION: 00 03 3
BUILDING AEDRE$$$S / ,/ -
,s,v /�/�J��✓� �•�0IM7 G��x/� SANITARY NO. APPLIGAT;ON SU �AaL,DATE
_ OW K' NA. , /tU .Vt9�7(0� „�///Ofi� 'y��I�GU \a'f/GN `/
NIC CONTROLN
Ir QN, 0 C/ 9s9s�s El
ARCHITECTIENGINEER BULDING PERMIT INFO
�- �o-�•�- ys�2 .
u
LICENSED CONTRACTOR'S DECLARATION
OZ r e I hereby affirm Nat I am ablas
licensed matter Provisions of Cher 91<ommercing- Job Description ,
F=t_m wichSection 7000)ofDivision3ofthe Bminesaad Dnfeniom Code,ad myliccmeis .
D ani c.
v_.O< ARC all be use DECLARATION
xw a^ 1 undersud rose Plans shat W use u Public rtcads
-s licensed professional
OWNER-BUILDER DECIakRAION
Z a 1 hereby aRmm that I am exempt from the Contractors License law for the '
xr c -following reason.(Section 7031.5.Business ad Pmfessiaw Cee:Any city or county
which rectums a permit an crevunn,alter,improve,demolish,or repar any son.
a prim in its issuance.amores he applicant for such Pimm to file a signed peticmem
ySq. Ft. Floor-Area
Nut heislicensed
e sedpctint to the,provisonsof the Conn ,License Law(Chapter 1
(commencingwSection
ec 0of Division3 of this Business and . sCWc)mr
that he is pt therefrom ad!the basis fm the alleged c. arm.A,A.han of APN Numb OccVu a�launa
etioTnY
P
e
Section 7031.5 by any aBcanfees pemiuubjecn the pBieamo.cbvil ma[ry of
j L
not more thin five huodmM dollars f3500). .
❑1.aeowoatrNegope.y.amy<mployeeawiNw.geeuNeumleeompewtion. Required Inspections
will cloth.work.an lN.strtelure isnot intended oroffaN forsele(Sec.7W.Business
and Pmrfecome Code:The Ctrtracmis License law nor does napply 10 an ow.of
property who builds or improves chimer.and who does such work himself or through
his awn employees,provided w1 such imp rvcmcnu an,rot intended or offered for
We.If,however,the Wilding or improvement i,sold within one yearoroomliletion,the
owner_Wildtt will havo the Wndcn of proving that he did not Wild or improve for par-
pose
❑L as owma of the Sm.70 ,B exclusively confessions Cod I To,Commenun U.conswn the es.,, (Sec.706.Business and Professions Cee:)The Convectors Li-
cense law does r such
m U owner of proPWY sour Wildv or imprrvea thereon,and
wbense Lasts for such project with a conhactmfs)license pursuenOO Ne Contnclors !�
License law. -
❑lamexemptuderSee. .Bk PCfor this trason ,
'Owner I Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following deelamtime:
_I have and will mrintain a Certificate orConsent to self-insure for Workers Cornier-
tion as provided for by Secure 3700 of the Lauri Cdc,for the performance,or the
/'y r which Nis permit is issued.
hYl have and will mammin Workers Compenmtion Insmance.as.,Suited by Section
3700 ofmhe Labor Code,for the x,rf.runes of Ne work for which this pernnit is issued.
My
m Ca.WiohS�� �ia6 �ylsa and Pol : nib,
cn o7Policy N. Irr
7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE a
(This section need nm be completed ifthe Forms is foronehudrd dollars UI00)
or loss.)
I certify Out in the performance of the work for which this permit is issued,I shat - -
.or employ any person in any manna so as to become sobjecfto the wurkne.C.,.-
smion laws of Califomia.Date "-
Applicant - m.
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should f
become subject to the Wmkds Compensation provisions of the labor Code,you must - -
forthwith comply with such provisions or this permit shall he deemed revoke.
I
CONSTRUCTION LENDING AGENCY
Q I hereby ulGrm that Nae is a construction lending agency for the petfunni of
rthe work for which Nis permit is issued(Sec:3097,Civ.C.) '
For4 Leaders Name
} lendds Address
W I certify cher I hive read Nis application and natation the.Wve inftmulmn is
0. Qrrect.I agree m nty comply with all city and couordinances and sus laws relating m
.T Z building construction.and hereby authorize representatives ofihis city to enter upon the '
V above-mentioned property for inspection purposes.
W F (We)agree to save,indemnify and keep harmless the City of Cupertino against _
C] O liabiliues,jdgmenu,cmuad expenses which may in any way accrue against mid City
} GT7n conx9uence of the greening of Nis permit.
FY
in
OND'
STAND
COMPLY WITH ALL NON-PoINi
U Z SOURCE REGD TI Ns.
St,matureol'AppLictinul tm �¢
Ha W s MATERIALS DISCLOSURE
Will Ne applicanto r ¢Wilding rcsupanl store or hotels hazandaus materia Re-roofs '
as defined by the Cupertm lunicipsl Code.Chapter 9,13,ad the Heath ad Safety
// Type of Roof
DYea (Ilio.
Via the applicant or future Wilding occupant use egdpmem we devices which All roofs shall be inspected prior to any roofing material being
mil bvrdrus air cmWvivntsaspcFlnd by the Bay Arca Au Quality Manag<mem installed. If a roof is installed without kst obtaining an inspection
incO 1—�!rs/ I agree to remove all new materi "r inspection. Applicant
❑Ycs g
m Iheve mad rhe harardous matdas ces" murder Chapter 695 of the Cash- understands and will comp ith all non point source regulations.
tomb Heath A Safety Code,Satimu 25 3 ed 2553x.I uodmtand wt it the
Wilding iota rbc 1lyhaveam it is rose mpmwlbility to notify the occupant U Cl
of the Rely. inns whr us1 prior mo issurace of a C.III of Occu
Th Signature of Applicant Date
Owner m sutlwaad age Dare
Allroo- ove.rings to be Class`B"or better
-OFFICE
I
CITY OF CUPERTINO PERMITNO.
f BUILDING DIVISION• PERMIT CONTRACTOR INFORMATION: 00 03 3
BUILDING AEDRE$$$S / ,/ -
,s,v /�/�J��✓� �•�0IM7 G��x/� SANITARY NO. APPLIGAT;ON SU �AaL,DATE
_ OW K' NA. , /tU .Vt9�7(0� „�///Ofi� 'y��I�GU \a'f/GN `/
NIC CONTROLN
Ir QN, 0 C/ 9s9s�s El
ARCHITECTIENGINEER BULDING PERMIT INFO
�- �o-�•�- ys�2 .
u
LICENSED CONTRACTOR'S DECLARATION
OZ r e I hereby affirm Nat I am ablas
licensed matter Provisions of Cher 91<ommercing- Job Description ,
F=t_m wichSection 7000)ofDivision3ofthe Bminesaad Dnfeniom Code,ad myliccmeis .
D ani c.
v_.O< ARC all be use DECLARATION
xw a^ 1 undersud rose Plans shat W use u Public rtcads
-s licensed professional
OWNER-BUILDER DECIakRAION
Z a 1 hereby aRmm that I am exempt from the Contractors License law for the '
xr c -following reason.(Section 7031.5.Business ad Pmfessiaw Cee:Any city or county
which rectums a permit an crevunn,alter,improve,demolish,or repar any son.
a prim in its issuance.amores he applicant for such Pimm to file a signed peticmem
ySq. Ft. Floor-Area
Nut heislicensed
e sedpctint to the,provisonsof the Conn ,License Law(Chapter 1
(commencing wSe000tfaainn3 of this Business and . sCWc)or
ome is pttharefromad!the basis fm the alleged c. arm.A,A.han of APN NumbOccVuaP�launa
etioTnY
tha
P
e
Section 7031.5 by any aBcanfees pemiuubjecn the pBieamo.cbvil ma[ry of
j L
not more thin five huodmM dollars f3500). .
❑1.aeowoatrNegope.y.amy<mployeeawiNw.geeuNeumleeompewtion. Required Inspections
will cloth.work.an lN.strtelure isnot intended oroffaN forsele(Sec.7W.Business
and Pmrfecome Code:The Ctrtracmis License law nor does napply 10 an ow.of
property who builds or improves chimer.and who does such work himself or through
his awn employees,provided w1 such imp rvcmcnu an,rot intended or offered for
We.If,however,the Wilding or improvement i,sold within one yearoroomliletion,the
owner_Wildtt will havo the Wndcn of proving that he did not Wild or improve for par-
pose
❑L as owma of the Sm.70 ,B exclusively confessions Cod I To,Commenun U.conswn the es.,, (Sec.706.Business and Professions Cee:)The Convectors Li-
cense law does r such
m U owner of proPWY sour Wildv or imprrvea thereon,and
wbense Lasts for such project with a conhactmfs)license pursuenOO Ne Contnclors !�
License law. -
❑lamexemptuderSee. .Bk PCfor this trason ,
'Owner I Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following deelamtime:
_I have and will mrintain a Certificate orConsent to self-insure for Workers Cornier-
tion as provided for by Secure 3700 of the Lauri Cdc,for the performance,or the
/'y r which Nis permit is issued.
hYl have and will mammin Workers Compenmtion Insmance.as.,Suited by Section
3700 ofmhe Labor Code,for the x,rf.runes of Ne work for which this pernnit is issued.
My
m Ca.WiohS�� �ia6 �ylsa and Pol : nib,
cn o7Policy N. Irr
7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE a
(This section need nm be completed ifthe Forms is foronehudrd dollars UI00)
or loss.)
I certify Out in the performance of the work for which this permit is issued,I shat - -
.or employ any person in any manna so as to become sobjecfto the wurkne.C.,.-
smion laws of Califomia.Date "-
Applicant - m.
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should f
become subject to the Wmkds Compensation provisions of the labor Code,you must - -
forthwith comply with such provisions or this permit shall he deemed revoke.
I
CONSTRUCTION LENDING AGENCY
Q I hereby ulGrm that Nae is a construction lending agency for the petfunni of
rthe work for which Nis permit is issued(Sec:3097,Civ.C.) '
For4 Leaders Name
} lendds Address
W I certify cher I hive read Nis application and natation the.Wve inftmulmn is
0. Qrrect.I agree m nty comply with all city and couordinances and sus laws relating m
.T Z building construction.and hereby authorize representatives ofihis city to enter upon the '
V above-mentioned property for inspection purposes.
W F (We)agree to save,indemnify and keep harmless the City of Cupertino against _
C] O liabiliues,jdgmenu,cmuad expenses which may in any way accrue against mid City
} GT7n conx9uence of the greening of Nis permit.
FY
in
OND'
STAND
COMPLY WITH ALL NON-PoINi
U Z SOURCE REGD TI Ns.
St,matureol'AppLictinul tm �¢
Ha W s MATERIALS DISCLOSURE
Will Ne applicanto r ¢Wilding rcsupanl store or hotels hazandaus materia Re-roofs '
as defined by the Cupertm lunicipsl Code.Chapter 9,13,ad the Heath ad Safety
// Type of Roof
DYea (Ilio.
Via the applicant or future Wilding occupant use egdpmem we devices which All roofs shall be inspected prior to any roofing material being
mil bvrdrus air cmWvivntsaspcFlnd by the Bay Arca Au Quality Manag<mem installed. If a roof is installed without kst obtaining an inspection
incO 1—�!rs/ I agree to remove all new materi "r inspection. Applicant
❑Ycs g
m Iheve mad rhe harardous matdas ces" murder Chapter 695 of the Cash- understands and will comp ith all non point source regulations.
tomb Heath A Safety Code,Satimu 25 3 ed 2553x.I uodmtand wt it the
Wilding iota rbc 1lyhaveam it is rose mpmwlbility to notify the occupant U Cl
of the Rely. inns whr us1 prior mo issurace of a C.III of Occu
Th Signature of Applicant Date
Owner m sutlwaad age Dare
Allroo- ove.rings to be Class`B"or better
-OFFICE
I