00020098 CIBUt OF G DPERBNNO CONTRACTOR INFORMATION: �� � _,O O 9
PERMIT
tlU1LDING ADDRESS:
SANITARYNO. APPLICATION SUBMITTAL DATI
1m1595, B rte eg -31 - 99
OWNER'S NAME:
L�r-��ya� [a�'/i''�mol sof NIC CONTROL#
G..)�lJ� —I ICI's J.JIG1'U ❑
ARCHITECAENGINEER r BU WING PERMIT INFO
two lax r c a
F �z LICENSED CONIIIACI'OR'S DECLARATION
0:G I hereby suRtrm tbu 1 em licensed uM provisiom of Chapw 9(comtme,ing Job Description
with Section T000)ofDivision3ofrW BuainmsuaM Professions Code.end my licerx is
Recut, Litch"Choss Rnm. New i-wo -' car �a ra g�
« Liceve Class W,.M
LL
d 0 N De¢ TS DIEmr
F u O Q ARCHITECTS DECLARATION
E j,•�] I undeuaM my plans sled I W used v public rcc«da
ne
a n o e Licensed Professional -
w0^_ OW NERsBUB.DER DECLARATION '
r_z a 1 bouncy a(Sml that 1 em exempt from the Contrectoh License c Law co Ne
ouSO folloviswhich tine.,(enni( ]onstruBuu«sseWRafeviom Cones:Any city or county
a 3 which n,i"ounce.a permit re construct,pplit.improve.denarro u m repair any snucnrre App p
pn«tonscener«,ilwa9a the thesisionann for Cohpermiuoicasi,Law
(Chamen( Sq' f 4'.bas'or Area 12 vitlLJalj Q[1
Not he is licensed pursuiont m the provisions of the a Businces License Lew Professions
9 IJ1✓✓-� ee(G�j/C//7
(nal he is it{with Section 7")ad
nr of theegedneua,tion.al any Code)« APN Number that he is exmbt tinafrom aW ate baa rat the alleged exemption.a Any vmlation or �D Oce pancy Type
Section 7031.5 five
any eppOcam(«a permit subjma rh<eppliranno a civil penilry of
not more then five hu(dred dollar 155007.
O I,asowmrMthe Propertymmremplm'mrwiN"ge "a irsolccmnpenaedon, ' Required Inspections
.U1 dothe work sed the svuc«rt is rot i.tcMed«affe(ed fm We ISs.]Ofd,Bmineu
end Professions Cade:The Connector's License law does non apply m an owner of
progeny who build,Or improves rherern,surd who does such work himself or through
his own employaes,provided Uw such improvements art not inanded or offered far '
We,If,however,the building or improvement is sold within one year of completion,the
owoer-0uiMtt will have the cartoon of proving that M1e dM at Wild w improve for pur-
PA f We.).
I,as owner of the Property an exclusively contracting with licensed contrach rs to n
con I the project(Sea.](1ace,Business and Professions Code:)The Contractor',U. fl V
cease law d«s nm apply]en owner of mctor(y who W ills m improve thaeoe,&s
wed contractrfar sucM1 pmjccu with acontnmorls)IironsuW pursuem to tla ConUectots OCT O � �OQ�
uMr 1
1 est{undnf5�s:. D. f '
/W/ U Date BUILDING
WORKER'S COMPENSATION DECLARATION
1 hcaby aRrm under penilry of perjury one of the following dedmdau:
Ia`
1 have ped will maintain a tion 37W ofCimLal mCode.surt for Workers Co of the
urian, r provided(«rn Section 3]00 of the labor Code,fm the perfomurue of the
work for which ill pemrit is issued.
❑i have sub will maintain Wnrkefl Cornfaritatiom Insurance,h hisuiad by Sation -
My ofdMlabor Code,f«theperformance of thework for which Nixpmnit is issued.
C Worker,Compcnsetion Insurance cantoradPolicy number n2:
Csurtier. Polity O
CERTIFICATEOF COMPENSATION
NFROM WORKERS'
COMPENSATIONINSURANCE
(Thissstim.red was becompleted ifthe pemthu/wore hundred dollars(5100)
or I«ad
1 certify that in he do..,of Ne.,it far which this permit is issued,l Nall
employ any,perm.in stay manner x as to baomc ecu nces o the Worker'Compen-
.tion Laws of Cnlifomi i.Due
Applicant
NOTICE TO APPLICANT:If,after malting this Cadicsute of Exemption,you slwuld
becorm subject o Ne Wires rs Compensation provisions of the labor Code.you must
fmthwiN comply with such provisions or this permit shell W doemed nevokW.
CONSTRUCTION LENDING AGENCY
O I hereby strum that rlaa is a construction leading agency for the perfomuwe of
z the work for which Nu pcmdt is,
suud(S c.7119],Civ.CJ
For Lenders Nems ,
7 larder's Addax
1 Q I rectify dor 1 have read s an li awe that the above infomation is
V O cone,(.l agrcc to comply with OR do ty #dimmer and sax laws Misting to
Wilding construction end hereby a h er '.cewwm of this city to enter upon the
above-mentionedro
Property for has 'on pulp nes.
W H (We)agae m save,idemnif end keep harmless the City of Cupertino against -
O U )ibilitim,judgmems,conatus crpenxs which may in any way accruO.Immat aid City
} W in Iomega,«c of the gra.Ung of this permit.
F � APPLICAN'T UNDLRS'I'ANDS AND WI LL COMPLY WITH ALL NON POIN'r
V z SOURCE REGULATIONS,
Signa«rt of Applica
HAZARDOUS
DD. ✓� � i7�aC�GGCr
A]ARDOUS MATERIALS DISCLOSURE
Will the applicant or futum Wilding Occupier store or ba(dle haaudvers maalW Re-roofs
in defined by the Cupertino Muni9ipaI Card Chapter 9.12,end the Health and Safety
Code.Section 255121+)' ( /N\ Type of Roof
❑ve,.
Will Nc applicant m future Wilding occupx(use wuipnem w&Aea,which All roofs shall be inspected prior to any roofing material being
40 r(dl'ardcus air conaminana as defined by the gay Aru An QtWiry Mutagcmmt installed. If a roof is installed without first obtdining an inspection
❑Yes X. I agree to remove all new materials for inspection. Applicant
Ih.ve the,area, ,.m',ands,,airementsunder GlapMrb95ofthecali_ understands and will comply with all non point source regulations.
ramie I safely code. oro 25505.25511 std 2553x.1 uederstaW Nu if the
M1uil g a tMnt1Y tenmLthu'tismymspmoibdiryto fy the occupant
to rs,uama ofircani f
our e ramie np t�a Signature of Applicant Date
Owner or avthonzedagent f Dam
All roof coverings to be Class"B"or better
OFFICE