00020129 CITY OF CUPERTINO - PEWITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: y/'N� ) .—/r ��/�/•
BIALDINGADDRESS: - "V�� V /' 2- /
s SANITARYNO. APPLICATION SUBMrITAL DATE
WNEF(�/iNApME:fk•� 'f'•1p�VY1..�a 1y�M1-- �C 3 1 R
g t 1�, f • lJ 1 e Asp- ¢
NIC CONTROLp
HONG'
El
asrirC11 ECT/LNGINEER ' _ BULDING PERMIT INFO '
w c! r 1 ^
dEm I
Z.O y 3 .LICENSED CONIRACTOR'S DECLARATION ...
O Z� '1 h.eby affm that 1 am licensed under pmviaimr Of Cheptm 9(comenencing / Job Description '
F_F'v� WshSetioe]000)ofDivition3of Ne Buutassand Rofedom Cade.and mY Wemeis '
Lioem.CImus B t New two..ca r 9 a ra 9.-
!y9!y
8OR! Licen.n Cless WON
t3 3 16i,y Dan, Connector
:•C Q ARCHITECT'S DECLARATION
G 5 r 1 und.ntud MY
"Wel"I be used u public ecwds
Pronfindmill
'vS_ OWNER-BUR.DER DECLARATION -
QI herchy eRm that 1 am acme from Ne Contruml,License Law for the " •
t m following ealon.(Section])3 1.5,Buaieu and Profeuiom Cade:Any city or county
3 which resume;a permit to alar,ar,improve,demolish,or minoran smctwe
, v
pnmtoit-mrumcr,alto orquie.lhe.,hram fm.wh permit tome e¢ignndtaemenn S t. Floor Area a
she he is Remind prrosimm the milwhiom orf Na Coma ars t_Iceto Law(Chatter 9 LJ`�
(romnrce'in$with Sstion 7000).f Division 3 of the,But.and Probeitiwu Code)or a.J
Wt he is eaempt Neefrom and de Wire for Ne alleged clamption.Any violation of AP Number Occu 3nC
Seddon 7031.3 M1Y any.pplican�Por a peemh mbiats Ne applicant to a civil penury Of '� Q I P Y 1YPe
rot mom Nan rive hooded dell.($50a)). - v .,• ,
.. ❑I,a:awnearNel,mprnY.wmYamplOyre.wiNw.ga¢..Nair.aleaamparo.dan, Required Inspections
Bl dO rework,Coda:
The mrcisnmt License oReadrwill ,Iy to aa,Busi,of '
and Profesaiwu Cada:The Conmctma and w1 law dors rot apply toff caner of
p 9 o ny who Wu11N te imprwvo thermal,and who doe such tinte dee Orr or though
r
bis own employes,provided that each improvement ase non intended w offered for •
• We.lf,nowa¢eA Ne building or impiov<mdnl is canal wiNin oro yw ofwrrwldian,de -
M) will have the Louden Of proving that W did ma Wild w mairensfor par-' '
rule.).
XZas owtw of the properly son,id owely couracung wish licensed conuadon m
burINe pajan( .7114.But inw lad Erotical.Calli The Cormclo"W- 1r��
cert law deanol yto an Dorm.Of propmy who Wilds Or impavee tlweon,and Y '
who came mlel¢wiN tor(e111eerMmootantta to Conracus', I.. ' -
'. AU
❑lam Lem eI .BB f 's
Ownernew "•1'
WORKER'S COMPENSATION DECLARATION r BUILDiN ..
40 1 hard avaffirm under pndny of perjury one of Ne following deluuiona; I�C7
7lheveand will maintain eCenificam of Commua self-insue for WOh.Ya Compen- - ' ' -
'on,u providnd fa by Section 1700 or the labor Code,for the perfomune of the
work for which this permit is otwe, -+ '
❑1 have and will maintin Workeh COmpemation I Tommie.as tequied by Samlm 'x L
3700of shc Labor Cola,for e perfomance of the wort for which Nis pcmil is issued
MY Wwk<Ys ComprnsalN
out Inane closerand Polity number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROMWORXERS'
COMPENSATIONINSURANCE - I
'(This suction need scan tecomplaod 1f Ne Fertile is fnrorc hundreddellae(SIM) -
or Ice.) . . .. .
Ienify Nal in Ne saAwmaneO as
bac rw which Nu pemlil icons.Ca shd1 '
nm..L,w,any .film in any manmr ao as to become subject w the Wank.n'GOmp[o-
ApionLnw¢o(Celifomia:Dve
Applicant •. ..
NOTICE TO APPLICANT:It,after nation,Nis Cenificae Of ELenlption,You should _ -
become ebjet to the Wwtr/¢Compensation provisions of tc Labor Code,you mutt 1 Z '
fanbwit comply wish such pros won;or his pcmh dull W darned evoked.'-
CONSTRUCTION LENDING AGENCY - I
z 0 1hoodaY affirm Nal demais a construction lending agency for Ne pen(mm�nee of I >'
_z Ne work for which Nia pumiI isiuued(Sn" ],Civ.C.)
Name
Lands.Nae
Zj j Lander.Address
4 A I certify dw 1 have foal n .ora that the above udemeam,is
Z comm.I age.m comply wit tit and ant a and.ue laws re Wing to
building con.mction,and here ya en iva Onhisdlymeneruponte .
V above-mentioned properly for Impeuwn nposes. ^'
[; F., .. (We),ere m ave,indemnify and lace,humbles,Na City of c.,.i..'sunt
0 V Imbiliu.s,judgnnim,costand npenses which may in any waYaccrwagaimn said City
�r [� in consequence of the granting of his palmi).APPLI } .
VF SOURCE NT REGUI GONSNDSAND WILL COMPLY WITH AD.NON
� tiOURf.E REGULATIONS.
Stgnuwe afAPPlea � tor Date J �� , f '
K!- HAZARDOUS MATERIALS DISCLOSURE LCL s
&
Will the pupc Or falai Wilding acu"",.awhandle lmeuffi smsedal Re-roofs
_u de,Sec by the Cupcnino Municipal Cod..Cluper 9.12,W she HcalN and Safety
ende.se.Retus3z(a)7Cl yet Type of Root.
'- Will the pplicamarfu�ildmgoccupmlmecluipmentordevice.which All roofs shall be inspected prior to any roofing material being
emit hasuious air conuunZen
thad by to Bay Am.Air Quality Management installed. If a roof is Installed without first obtaining an-inspection
Disuicl]
❑Yu �I agree to remove all new materials for inspection. Applicant
Ihave ,;,,, uitemmtaod, C understands and will comI with all non point source regulations.
haps 6.93of de Cali- P Y•ramie Healsh of y 303 25533 vd usJ4.1 a Land Nm if Be .
>building dors mcu vale moan m is mY m.pon¢ibility
Ne egdifyAh pant
Of au t of CUT
owmrna ioui.daed...m 1 - Dae Signature'of Applicant Date
All roof coverings to be Class"B"or better
OFFICE