00030195 CITY OF CUPERTINO UN'I'R,� 'OR CNF`CIRIYIA'�IONs PERMrr rvo.,• -
BUILDING DIVISION „ PERMIT -
>• 'BUILDING ADDRESS:
SANl1ARYNO. APPLICATION SUBMEffA DATE
NIC
R CONTROLp
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V/L' QL¢ -A05' '
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PHONE' N / of l NB�I J ❑:
5 ov /l�5 75-x2
ARCHITECT/ENGINEER , e BULDING PERMIT INFI)
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Shc�'iAl2 Asaci4� Z/ 5 3
Z
o>3 'LICENSED CONTRACTORS DECLARATION - - y ,
I hereby affirm Nat I am fc a Bu under pmvinams of Chapin 9(commencing _ J_ m Job Description
.�y with Sccbon]000)afD ion3ofthe Buemess end Pmfnaion. 1.d . mI Lb r v r
<y�qW] inf llf wdeRed ;. )'fF l ]
L.0 w U License Cl u - Lic.M' .1 . - •,l • n • r
o a N Dale Convector' )
5 C¢ 'ARC 'S DECLARATION i R oIn1G �' ltliNDocJ rD RPL M04
IN •] undenmM my s ahrl' sed es Public recoil, / f a.
N
'd O- tufo wr
k ' OWNERBUB. DECLAMTION
t Y I broth ff Nat I am exempt from she Contractor's License Law for the
I. o follow ng re (Section]031 5,Business err Professions Code Any city or coo ty �.
w., wn cis rary patten m nomwa ilmr unprore demouan,or repose env amemrc Sq. Ft Floor Area l>,'. $- Valuation Y'
poi tot '. a also requires the applicant for such smut to file a signed amtemrnt "� /s
Nat hes licensed pursuant to the piovmons of the Contractors Lrednse Law(Chapter 9 SlO aQ rJ -
chatbencngaN$ecuen]000)ef basison3of aReggalanendon A ionslrftan APN Number ccd ane T e
Nath i exempt b taaefrom and the assts for be allegW exemption Any violation of l P„ Y,YP
iso 1the 5 by y ap d doll fora permit mb3ats the applicant ivil penilq of '✓ _ _O� ��/i• t
l more Nw fve bwNrd dollen y employees
.O'Iasnwna o.Neprnp.Y•ormYamdm'eed viNwagaaetheirser,cmmpenuuess - , Required lnspeehOBs .,.
a will do usioands: awcmmisnati Licensor Law
redi does nt apply to an Business
of '
and ProfessionswhbCode:The C cxuthereo License law dos trot apply to an through of -• Y e
a t props.who builds or improves Hereon and who does such woo himself or tied for ^
- hie own employees,pmvided than such improvemems`me not inmMW or offered for •.p � -
srel-build vacifth hue the
gorot of prmern lssoldw id. Wildcofcoinple for
held 'II have Nc burden of proving Nat he did nm build fir improve torpor s
pose fiefs l' .: ':
❑1 as ownerf the Progeny,am exclusively contracting with licensed corrections m `
f an,. the p mmt(Ser 7004 Business end Pbefei nuns Code')The Contractm'Li. t `
cense taw dax note 1Wen owner of who builds or im thereon.end
.such pot
property proves /
whoconwcm for suchp 3 tsw Naconvado(s)littnaal pursuant to the Communes /
Licence law r " X•q `/ - '1'
❑lam exemPtunda Se .B&PCfoi thrs asses A,s - ,a to •. 1 4 Fy
Own<r . ,c '• Dem ' S "•'i ,.
WORKER S COMPENSATION DECLARATION - . -
•"r•I hereby affirm under penalty ofpepuO mte ofma toll sgdec117one .
.0Iheve and will-none a Certificate of Cinema to selfinaure for Wmkers Comps r r
satin as Provided f -b Section 3]00 o the Labor C fm the ifomnna of the .. w. •- -
work For which this omn n issued. „ '
W
1 M1av<and wi mein Workers Compensation Lmurwca req d by Section
37
ade,f an frac work for whihNu p:rmti's is W: '" 'S• n
y a - and Policy numbs are.
Cam on on mrwccc a No.:
CERT ATE OF IT NFROM WORKERS '
COMPENSATION CE a r;
(Thrssectionn ednm becomplaM fth pemitnforo efiundred dollarslS100p , ,y- -
6,leas) -
IminifYNat in the pertmrmxuceofthe work furwhmh this From nisaued,l shell
• not employ any person in my manner so as to become sublet to the Workers'Comair-,
sultan Laws of Collfoml9.Data •F -
Applicant r
NOTICE TO APPLICANT:If,after making this Cri iRcam of Exemption,you should '
-necome sublet to the Worker's Compensmen provisions of the Labor Code,you mast )
foMwith comply with such pmvinons or this permu shall h named revoked.
Y '
CONSTRUCTION LENDING AGENCY L
O Thereby uRmi NnN saconnmcti IMmg agen yf the pcA men f 'a
a,Z-R the workfor which thisp stet s issued(Sm.309] Cis,C.) -
Fy' 'lend, - No.,
-_ •' .. s
f(y' lett ,Address - ,• .. _ , .
I camfy Bw I five read this application end nam Nal the above information s - 3 - x,r -. ,
a Q comet I agree c comply with all city end county erdlnancof and i m laws r up g t
.r1 Z •iumi-mennaWctiro end forebyamhonu«oses. lines of Ilii city to airier opo Ne + • 3
V Q 'above mentioned property f action purposes. t
W [.y (We) gree b revs indemnify and keep barmlas the City of
Cupertino ego tet - - a .a
O C.7 liabdiueerydgmema,secantred xpenua which may'n any uaymmeaaioitut OCly { 1 s lie
�•r. W in consequeaccm the granting of this permit. ,y. n
Fw'Oa APPLICANT ' )ERSTANDS AND WILL COMPLY WITH ALL NON-POINT e
Fw .OURC' LAT EONS V d 1
nmureuf Applin Comowt Dae _
HAZARDOUS MATER ALS DISCLOSURE - ,
Will applicant or future Wilding cupant store or haste hazardous material
ere dcfined the Cupertino Municipal Cade,Chapter 9.12,end the Bart end Safety Re-COOTS
Cad Sa 2553ua). Type of Roof } ''
pto
,Dye _ — 3 A'll roofs shall be:irispected prior to•any roofing material being !-
Will th ppl'cant future W INng pent use equ p t r dmim,which f
emtha>erd zai;non mn�xtaado yAreeA Quality Management .installed. If a roof is mstalled•without: trst obtaining-an inspection '
,Di eft'"? e
Yess I agree-to remove alFnw'materials fon inspection `Applicants '
❑
No ' - d n.
un ers s and-will'comply'with all Inion point sotirce.regulations.
1 have reed the harardaus materials requirements under Cluptci 6.95 of 1W Cash-
forma Health&Safety Code,Sections 8505 25533 and 25536.I mrasuM that if the I
building dors nacumently have a trend dsaurismyreapmsbilty mnotify Ne acneplaneK,. 'Y4 it
of the oci uemems which most be net prior to issuance of a Cmuncate of occu
Sinature ofAppl' ant f Date - a.
Ownar or autho6 rangent• Ovale {'
- r AIl`roof ousting,to be Class"B'.'or better - -
. •• OFFICE "
r ti.
1