00020133 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT' � ON�+RAG`I,'OI}'.INF R1V A"I;I�N: a CO2-
BUILDINGADDRESS -
•��, !' ,r`I ••' :', ' r r _ SANITARY N4r APPLICATION SUBMITTAL DATE
` WNER'q NAME: ..d
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NIC 'CONI'ROLN. „
OM
INFO- . 77
CHITECTIENGINEER ?
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y LICENSED CONTRACTORS DECLARATION .JObDOSCrI t10I1 '
O Z=n .1 herel y amrm don 16 licensed umber provisions of Chapter 9(mm becon.g ., +• P
wimh Sects 71)(10),dDMsion 3 ofthe Busmwsand Profmisto..Cade roularyli I�{+`-I +' /'k (^ -
�� in fullf ce and effect. '+ ' _ Ne-w I ,y yQ GVk1 ' /Na (^�y'/'•a�
in Nil a Clan Lm N ' 1... 1 //yy'��..�t 11• lV./11``VV'��
3 I-
Datec cony«sur - -
I.,u O 6 .ARCHITECTS DECLARATION j
um 2, I undmtW ch;Plans shall b,used as public rcmrds
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Lie ad mfinsax,m] r / Z f7 V •T.
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OWNER-BUILDER m the CoATION ' L•• .
•'I in. affirm mat t em exempt from the Corrin,C i.scenes Law for me . t• -
E Z O sviddC a iia (Santo 7031.5,Business and Pmfmlona Code My city arm e '
F e wM1 r I it. - e.W n w W. .a.th..a1w improve h permit 1 fi repair sty rwctwe -
3� - Sq. FL Floor Area� a ua prior In is
parsuam'.di6 d10 applicant for Con permit License aw(Chae ant � - -
that he ie licensed punmm this provialons of the Canlnnth License law(Cluplei9',
(<ommencmg wrm S«uon]OOO)of Uvnmtv3tf the Bu.inma antlH f 'On.Codc)m -
`Net he is exempt thacfrom and Thi burs far me alleged<u w .Anr adal,dan ar +APN NumbsA ,Occupancy Type
Scioto 70315 by any applicant for a permit subjects the applicant to a civil penury of
1 man five bur ned dollars(5500)
.D1owner ofthe property.mmy. employees with wages u their sole compensaun +' o ' >f• Required Inspections
t will dome wok;and meswdurc is Troth inwndedoroRemd toruli(S«.]Bba,Buumsa + 1 'r
�amf Professions Cade.TM Contractors License law does not apply.to an owner of ^
Inn ,who builds or improves mermn,and who does such work himself m through'
bat own employ,, provided con such improvements arc not mundrd or offered for
r nate if,howevetme building orimpmvemenus sold vnmmoneywofcomyluion.me
-0uilder will have me burden of proving mat he db nm build or improve for FLIT - - -• - d. '��°, •
of salol "
1.ace owner or the Property.Ont exclusively convecting with licensed commacwn to
julaup.,me Frolic,(Sen.]OW,Bu nes.and Profeasios,Code:)The Conaanor's Li-
-a. LawKil a en owner bf propmy who budda mpr a thereon and -
who o «v rm abontracmr(r)IicenaM puramntwlhe ower es ,
Dimon :,_ BffiP f
'Owner D rw 111It,n ^ n ff��aCe .. .
WORKERS PENSATION DECLARATION
I hereby affirm under penbry of perjury come ofine fol, g d«lam moi -
} I have and will numw,n.Cerificamor Ctnsent w selfimm -fe Wmiceer Coope- 't ,.• AUG-'•1 3' 2002,• • - '
non..s provided Tor by Section 3]00 of the Labor Cade (o ,he percorrmnce of,he '' °-o'
ink for which this me,is issued. s � .. '
❑I have'and will maintain Workers Compensation Insiuoc gored by Swim B U!L ®I��
3'l000f the Labor Code for the performance of me ink for whichths pimotsRo ed d DING . ,
My Workers Compensation Insurance earner and Policy number am. } 1tl`7 '
Carrion Policy No.:'--
' .CERTIFICATE OF EXEMPTION FROM WORI(ERS' r
COMPENSATION INSURANCE s ^
+ ('lir sermon need Trodbacompinedifthepemdlisfmo..huMrtddollars($1W)
or less, !' -
t Icemfy that in theperformance ofine work forwhich this permit it issued,l shall
not employ any person in any roamer m as It become subjec o,the Workers'Compact-
(satioou Rcf Celifomia.Date
Applicant' ° 'l, • , r r
NOTICE TO APPLICAM':If,aster mating coir Ccr ificaw of P,zcmpuon,you.hould' '
become subject to me Workers Compensation provisions of me Labor,Creu.you..at �• .. 'L.
(onhwith comP1Y with such provisions or iia pennh shall be d«med revoked. al ., ,•E '
z CONSTRUCTION LENDING AGENCY• -
�,p Iherebyaffui.matthneb.,omaum;.lending igency for the psof.cetf' -
Ne work for which this permit is issued(Sec. 09]Crv.C.) - • '
Fy Lenders Name
a' Licorice.Addie._
certify con I have read m' app cat n .vie dist the above inf Rmrmut i. d - • .. - -
f5a comer 1 egmo t mPly wW all J c u minces and awe laws relating w ,
z build ng o wcu- dhircby mhodu pr to rvia ofth itywenvruponthe
abovennnna=d Ompenyforms....puryo es. 5
(W).gree w save mdcnnmfy.nd k p harmless the City f Cupem.o agmsi r - -
U -liablir judgmems,coauandexpemawhchmay.anyway ccmemainnumd City
syr. Lia in c asequence ofine granting of cors penri t � ' '
:' a is
Fr Qr APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT r' -
V G SOURCE REGULATTONSI' a
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% Sign wreor Apphcaut/Convaclor '• Date
r HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumrc building xcupenlsmm orhandle hazardous mawrib Re-roofs, a 0 -
�io dcfined by the Cmipemno M nil I Code CMp[r 9 12 rob me H bin and S.f tY u r
cact s t xs;u(o Type of Roof
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Will+N epPlcadtorf am Wilding cupmluse equp , rJivmttrwhih 'All' shall be inspected prior to any roofing material being
cmithramins air containments as defined by the Bay Area Air Quality Managemen, installed. If,,a roof is Installed witholkfirst obtaining ananspeehon
all°``""cl .�./� I agree to,remove all new materials for inspection, Applicant '
❑Yes `J�No v ' • � ' d
(hiv e - daamta'naTareguh..—m?nn&,rCitti 95 of the Cali- ,.un erstands and will, comply witti^all non point source regulations.
Enron OR ffi. c ode.Sections 2550,25533 and 25534.1 u sub that if the . 't 1:~• s '
building ser ly haves sun. m uncri emomibility Yoe , upvit - 'm, • r
a ofine re he 1 'c " co p su s..no a Corti
Signature of ApplicantDate
Ownero mo zed age.[
Data • d _
All roof coveringsdo be Class"B'°or better
'OFFICE