00020201 CITY OF CUPERTINO PERMITNO,
INON RI A+ OO N<
BUILDING DIVISION PERMIT C►OO N1'RA TOR O a b 9-N b05(0
'BUILDINGADDRESS: -
t �!,✓) A.I,�I'Cc-� •,��S"� OCf SANITARY ND. APPLICATION SUBMITTAL DATB I
. •-r'- l_ IFIL- LC .
OWNS AMH:rest . .o r I,VO -
.—.A ,M •• 1 TJCJ•� J �'c N/C, CONTROL#
IONS: eCT.' �Y1012�/kN FP�.��j C r1 , o
C? Q
ARCHIT� lSCRO �S'd�7 ' ItUI?UI,GF.ERA4ITfINfO
�E
�
Nu
z O y= LICENSED C'ONTRACTOR'S DECLARATION
O z-° 1 hemby aifin t Nat LICENSED
unlicensed under provisions or chapter 9(cummmcmg Job Description
o Loi with Section 7000)ofDivision3ofthe Bmms..and Profeasiom Cade,.nd my,lice.is •
�z�a inrau sorts and t. S2—�r-?3 \ / t
SQ�uO Usama Cl Lic.g 0f_L ' f OT✓e �Il-- "`IL' M1-�T!'C�
III--- LLO g Dale Contractor
ARCHITECTS DECLARATION
4 vW< '1 underuaros my plam.hall be usM u public m mind
0 Llceeell Profeasloml -
vl se
OW
NER-BUIMER DECLARATION
I-Z_'u' 1 thereby affirm eat i am exempt from He Comustols License Law fertile
rt° foliwring rmmn.(Section 7031.5,Business and Rafwione Code:Anr,city or county
F which ulrts s it w counteract.alter,Improve,demolish,or rt structure
0.3= priors its iRmnce.also inquires he applicant for such permit to Elea igtKienrolment Sq. Ft. Floor Area " Valuation
that he is licensed pursuam to the proviu n;of the Contractors License Law(Chapter 9
(commending with Section 7ao0)of Division 3 of she futures and Prore.iiom Cache)or APN(AIUlIltler Ocw ane e
Wt he is exempt therefrom and da basis for Ne alleged exemption.Any violation of y Typ
Salon 7031.5 by any applicat fm a pemdt subjaa Ne applimt to a civil ptt ty of 2 �.
pt mom Nan Ove hundred dollun(5300). ,
I,asownttarNepraparty,mmremplpymwww.gesastheiraleenmpeeutiov. Required Inspections
and
Prolamines
Cosec he Cont u riot i License
fmselcpply 70ad,Budmu
and RofeNom Cade:The Co s tbers License law doer nm apply s lf owner h
property who builds or immava ancon,tad who daaa such work himself m through
his own employees,provided that such impronammuns;w art not inns-of or oRored for
tole.If,howevw ll have ding m len of min lth aid within t b yeas r inapt for For '
wmr-coo).will have Nc burden of proving NC he d'W not build or improve for pC- -'
pate ar 601E.).
1,as t meer of s sm.7 .m c Farniers am caetruain8 with:)The cronaacron .construct Ne project(Ser.70sa,owner
of
and Rmwho builds
Cade:)The contractors and
mnu taw, is f not apply m ts own[or proton who build.or impmvm thereon,and ^ T
whence Lacs for such projau with acontracmr(O licenaW Ferment to the CantrecsoI
License rico. r ' '
❑Iumexemptunder Sec. - ,BkPCfmt1rxwon '• �1 • .
Owmrl .. Date 'o J
WORKER'S COMPENSATION DECLARATION
1herebyil manunderpeaty oe perjuryarcof Oafollowing erscesCo
Ib've'ndwill for
neCion 37 a ofComenuo self-inawe fe WorkehCampen-
cation,[provided for mi cation 3700 of she labor Cede,for the perforrnana of Ne ,
which this permit is issued.
have aLa will maintain wmkels Compensationce otw Insurance,h required by Section
or o,11,
Labor Code,for the pciformenco of the work for which this permit ir.iseuW. °
My Woheh C rte 'on Incurs cudtt and Policy
C y !!: �_Policy No.: /Q•S�S�-�r7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seerion mull trot bee leel if Ne 't in formahundred ddlue$100 - '
ting p m
or kaa.)
Roy an,NC ins.my performance of N1.beene work rwhich ei.theWmkt is ewConter-
not employ any garcon in any manures w as m bcmna subjauo the Workers Counter-
Wine
,
A,li awl of California.Dam
NOTICE
ml
NOTICETO APPLICANT.If,afarmeting this vision of the
"hour on,you should '
M1a witt,' fano Oth Wohers Comn,or 11ti. ❑revisions of tlro labor Cade,you mins,
forthwith comPlY with such proviaianv or Nis permit Wllhdatrcd rtvoked. '
CONSIRUMON LENDING AGENCY
Q thereby affirm Nes thte is.conumcdoe leneingagency,for NC performance Or .,
the work for which Ni. mmil is issur/(Sec.3097,Civ.C.)
a
Le"race:Name
1<mice Addre..
W I cenily that I h.ve mad Nin application and stat,that Ne.hove Infmmuian In
0. correct.l agree to comply with dl city ruunholinesmetal county unholiness asttuc laws selming to
.7 Z buildiogcammxdoe,eml hereby authorise repmenmivn of Otis city tomer upon the _
U C above-tm uimad property for inspation pur osea. ..� ,
ks E. (We)'Fee rn save,indemnify am kap humless Ne City of Cupertino.Baird - r
Q V. liabilities,judgments,cmc and esp..which mey in'any way acme,turens said City
in consm ueme of the Bmming of this permit ;
FLI
APPLICANT U NDS AND WILL COMPLY WITH ALR.NON-MINT
SOURCF . RATIONS. %J _
sigvCrt of ApplicenUCt �V� /'T�/,,(,/...UC`af /ice
HAZARDOUS MATERIALS DISCLOSURE
Will
anch AA OOff
Will thmeCupordoo t or Muniapal Co Code.Chapter
mantle ha.Cdouatmafial Re-roofs'
C defined by the 32(4)?no MuniciWl Code.Chapter 9.12,eM the HeilN and Safely
cads,cation us33('37 'Type of Roof
' .(]Yes QX5` '
Will Ne epplians or fuwrt building mcupmt ata equipmem or devices which All roofs shall be inspected prior to any roofing material being
emit hvardous ah'ronamione, a. wdbylhe Bey Ares AirQWity M.mgement installed. If a roof is Installed without first obtaining an inspection
1 agree to remove all new materials for inspection. Applicant
❑Yes
Howereadtbe hCardoua mamdeL rryuirtnrtna ulider Chepmr 6.93 of Ne C'li un er ill comply with all-non point source regulations.
format Health&Safety Cade,Sermon.23505,35533 and 25530.I uMusund that if the
M1uilding docs note ndylnee inn that it is my respwibility to notify Ne meuPam, - —�� `O
fthem ns whi incl pdwt�mna ofaCendicaa of cu - - � e L�
mroraallorizM.gen ro ata Signature of Applicant Date
All roof coverings to be Class"B"or better'
% :OFFICE '