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HomeMy WebLinkAbout00040083 CITY OF CUPERTINO PERMITNO, BUILDING DIVISION PERMIT CONTRACTOR~.INFORMATION:,. ©�-� 0� C7r BUILDING ADDRESS: 1_ ,(l1 _ b ,`Vll-�1^"is^ft_gkjLQ 'tl'ks4'y SANITARY N(1. APPLICATION SUBMITTAL DAi JJs-r'3'c�.Q_ �f p^7 �] (�O OW. " 'S NAME: �I7� ! ? S' 0- &7--- � ,��— C �y�.� - NIC COM'ROLp AM HONG: z0'7 7 CLL.(.✓'Ql'Y� 5 1 0618 11 1 ARCHITLCT/ENGINEIiR e��3— DULDINC]PP.RMI"I'INPO I ""';ei<," 000 VUU t Gi Fo] LICENSED CONTRlu under provisions - Job Description Z p v_ 1 hereby off rod Nn I am fi Ru order provisions of mChapter 9(Commercial P pZ-p as-Fty wish Satfon]000)o(Divisian3of Ne Buvneuand DofeuionsOCode,Wmylkeueis zy�� in full forttW;R n.` '3U..# C.�V ei -y O ne u Lierm"C a s f J f s tLLoS Date. ARCHITECTSDECLARATO+ / '�) f(b1V, {�f(A4O�Pi( �QSrYC �lllT le �1 a 1 undcnaW my fA...till h usal u Public records ` ds20 Licensed eDthaniw OWNER-BUILDER DECLARATION ot C Z< 1 hereby sRam Net 1 am exempt from the Commerce's License Lew for the n e�C E s D followin8 reason.(Section 7031.5,Business and Professions Code Airy City a wunty i 3 With requires a permit to wruuuct,their.mx rave,demolish,Or repair any smmrate Sq. Ft. Floor Area Valuation prim to its ismencq dso requims the epplicam for such pemduo EleasignW mtemem O /aMpk U that he is licensed portion,to the provisions come Contractors License Law(Chapter 9 (cdheit'agwieh SaGOn]000)te, ivisioForms, rmrhe Busitw""avd Dorf Any vis Conic)m APN Number Occupanc Type tAet he is e.mpt thacfrom aW th<basis far the dlcgW exemption.Any violation of / �p Section]031.5 by any optician far a pcmdt subjects Ne applicant m s civil penelry Of StU oa V nor more Nan five handed doll.(SMOL I.as Owner OreMpraptuc.wmremptender widtwagean moiSece cnmpensiness Required Inspection awillnd d0ehcwork,ende: he:Con isno,intendedaoR,oul for does a. antl Pry wita,bolds re illie se.dcmrs Linn.law docs nor apply s lf owner of his ow.wed Wills pr improve tnsuch i and who lees such work deli or o through far his own employee e budding or improvement such mentis oldwarea are not iyaroft m OffeiW fm Wt. wric'-hOweveatne Wil the borer,of issolhe did. Wild ,i pmvefar pr, red tinier will tons,the buWen of pmvin8 diet he did nor Wild m improve for Pur p0.of sale.). 1,as Owner Of the property,am a.6tsoveyad convecting with licensed conuanon eo construct the project(Sec.]OCC.Boutros and Profusions Codei The Cmuecmb and! ^ whoa hew does rwt applyje m owner of property,wed andds or improvh therton.orad V whence Law.far such projecu with a conuector(q Iken.d Punumt m the Canveaors y License few. ❑1 am acmpt aider Sec. .B A P C for this rta+on , Owner Date WORKER'S COMPENSATION DECLARATION 1 hereby sAkm oMcr Penalty of perjury—Of for f011Owiog dcchmemes: �Iherc and will meintainaCemOcaa Of GOasrntm.IfnnxuRforWorker'aCompeo- .tion.r provided fpe mi it wai 3]00 of the Labor Cede,for Ne pcafomanee of ane work for which this umaiis issued. - ❑Ihaveendwillode,forWorkers ease of thin w Wfor which tmance.as his by Section 3]W Of the Ichor Code,fgporgqNe perfurmpmmce of ane work forrrrw9�hybyic�ahyytyyhis pemtil is issued. MYW ComposedCarrier AA.�Iw / Policy No I.aml Y s� d CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE pThis section neednor W completed if the permit is for ore hurAed"Ines(SIM or less.) I artily Wt is Ne any no a r, of the work for which this the W is issued I shalfe.- sa empmy any person in my manner,to u to bcconr xubjar m the Wwkan'Compen- .tion Iewx Of Cdifomia.Dare Applicant NOTICE aS APPLICANT:rs Co making this Provisions o of Exemption,you should =$I hecoarcsubjecty ted Wmkcro Compensation this pmidool of thetabor Code.you man fmNwiN comply with such provisions m this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY C) p I nemby scrum ma there is a c.nnruedon leading agency for the performanee of Z = the work for which this p.it is issued(Sec.3097.Civ.CJ e� +\ 1 Lewers Name I 1 J C > IaWer' Addrtsx D ' D W rchre that 1 have read um dehia application and sal the above information is Q. A I correct.I agree to comply with all city ell county Ordinances ad node laws rtbting in APR 1 3 2000 7 Z Wildingcrosuuction.aW ltmcby sutlrodm rtpresrnodivu of this city to enact upon the V OaWvc.memi.acd property for inspection purposes. Ira F: (We).gra m save,indemnify and kap haamlesx da City of Cupertino against V le lities.jalgmenls.amu aW upemna which may in any way Katie egaiut said City >. ICI in consequenee of eche groaning of this permit. 8y Iti a APPLICANT UNUERS'I'ANDS AND W BJ PLY WTfI t ALL N(1N-POI N'1' y SOURCE REG lIL1Tl('NS. / Slguxorx.-f A+— mtgO .m' Data HAZARDOUS MATERIALS DISCLOSURE Will ea.,dw.ra Or Pat.Wilding necupmumor m handle huandmo mmcrial Re-roofs u CcfinW by the Cupertino Municipal Code,Chapter 9.12,and the Health all Safety Type of Roof Cade.Settle.z53z(e)] / yP ❑Yu 90` Will the applicant or future Wilding occultism use equipment or devices which All roofs shall be inspected prior to any roofing material being trill heaudems ah conttaminmu a defined by Ne Bay Area An Quality Management installed. If a roof is Installed without first obtaining an inspection District] I agree to remove all new materials for inspection. Applicant Yes Ih.etecdtheh..rmaamaw.lrRnaiRmantaaderC,a br695a the Cali- f ali- un erstands and will comply with all non point source regulations. forma Hwlth R Safny Code...u. SDs.2 33 and 25534.1 uMmta d that if the Wildingdm trot curtrntl vete LNvt Yrtspomibilkytonaify6nosocupmt HNe sun scumy��eCmificare MOccupeney. roarir� _!/ Date Signature of Applicant veer or vu ed agent Dam All roof coverings to be Class"B"or better OFFICE