00050058 CITY.OF CUPERTINO ,;PERMIT NO.
BUILDING DrnSION •PERMIT 12TRACti 1 e INF f I A�T20O Na ��D
BUILDINGADDRESS: t?
5c� ST IIC7�wrhl� ��Ls SAN RYNO APPLIC =N$UBMfITALDATE
WNE ' Nil ?: '1 '7 /00o.'(�jS�y(/" /!-�sa�� " N/C .IC�ONT'R°y✓Ljk
PHONE:y .-y'23 [ D OD r e0AINv .V(l:/s- CA/ / - ❑ -
ARCHITEV•CTMNGINF.ER_✓ w g J f t 7 BULDING-EERMITJI RF•O
Z S N= LICENSED CONTRACTOR'S DECLARATION -
OZ- thereby affirm the 1 am licensed under prosismas or Chapter 9fcommevring - Job Description
Fh F� I
wish$arce ce7000).!Divicim3orde BmircseaMGPofwion6 cfodc.aM err fi«nm is . . /�J/�� [ Tp�/�\�
�Qr-aj Li«iue Glu+ <Bect. G�O Lic.N
k-El 1,TRCH1'IECT'S DECLARATION
I undenund my plans"I h used ex public sada
Liemeed Professional r
OWNER RUBAER DECLARATION
1 hereby affirms thin 1 ase exempt from Ne Con recrors License Lew f«the
f F O following reason.(Session 7031.5.Business and Profeeiau Code:Any city a county '
g F$ which rwuirea a permit on cauwct,after,improve,detaches,err repair any soucnue
K 5 Valuation
prim to its issuance,Jm scummy the applicant for such permit to fie a signed statement
Run he is licensed puraumt to the provisions of the Coumacmr.License Law(Chapter 9 -
(commencing with Section 7")of Division 3 ofthc Busfnee aMPnfeuimu PN Number Oe
that he,is exempt shertfmm W she buts fa tate alleged excerpter.Anr sister f umOccupancy y TYP
S w 703t.5 by any np fiL t(a a pnmit subjmc the applseent to a civil ml=(f
not more dun live hundred dollars($500).
I...of the property.or my employees with wages a Russ...I.mmpennafan. Required Inspections
will d.e."ork e x the...turc is net intended uroBerd for We(Sec.7010,Business
end Propmer n Code:The Comarmon's License law cars nor apply m an ower of -
ymperty who builds or Improves thercan,.d who doss men work himself or tluough
his own employees,provided the such impmvemenu a<not intended or offered fee
We.If,havevm,the building or impmvemern la sold within one yaaof completion,he
.wnu-Wilder will neve the burem of proving that he did not build or impuvs for par- -
pose.f We.).
Q I,as owner of the property,am excluzo,elY contradng wish licemed conpmton in
constants Ne Project(S«.7000,Business and limfneirns Code:)The Cortmors Li-
cone Lew does not apply to at owns of property who builds or improves theater,and
who contracts for such progress wish aromacians)licensed present to she Canuectit a -
U.se law. a
❑
l se Law. under 5«. .Bk PCfor Nis reason
Owns Due
WORKER
'$COMPENSATION DECLARATION -
I ImebY by,WORKER
under penalty of perjury man of the following declensions: ,
Lha«and will tvivtuna CertiOam o(C.nernuo sel4insure for WorkerY Compen- '
cation,a provided for by Section 3700 of the Labor Cdc,for the performance of the g
work for which shh permit is issued. I
❑1 hoeCompenmion 1 e,a requite - -
3 labor Code,':T70=de poIdle work io-hMxb this permit is is.on
worker Co ser' Policy b .
artier'
CE IFICATE OFON FROM WOII
ENSATI VRAIVC7� '
(This smon red trot be complend ifNc aadt is for.«hundred dollars IS 100)
I certify"tin the performance often work forwhich this permit is issud,I shag 1
not employ any person in my manner aro as to bmow subject u 0e Worker'Compen-
mlm law"of Cui(omie.Due '
Applicant
NOTICE i'O APPLICANT:If,after malting flus Cerificau of Eumpdon,you alauld
become sbbjun to she Workers Compenmbn provWorto of the Labor Code,you must
fiMwitb comply with such provisions m this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY t
0 0 hereby affirm the Nem isac.avucsian lending agency for the perfomuntt of
the Wworkk(Ofr whichWllLh dila pef1n11116issued($«.3097,L'iV.e.)
it1 rder6 Name> Ieoders Address .
fat Q 1 cenee duo 1 have with
thio appli tis ane ante tha the above mromudan i,
Q.
corral I agree to«roan with til nt m u tY�adlye. sere ..a sinsom on
'I-) 2-e 'ationengconsnedpromd haseby for
esenutivev t uioy to enurupon the
+ "U � above-mentioned property for iapectio u"
Lr. Fy (We)agree ro eve,i demnifY a kee leu ty of Cupertino age."
V Habili'a,jodgoren Lau depose hic yinm w areae age..aid City _
} fa7 Inc encs oft gam gof this it. - -
[� In Ann ISM U111" RST Dg AND111.L( MVLYW TIALL NON POINT
V SO RCI REGUTA
igen ApFbrmtuC minor Dec -
HA DOU$ TERIALS DISCLOSURE
W theapplicm or uture bus ding meanness store orhmdle haedous mataiu Re-roofs a as deli by the Cupm no unicipal Codes.CTapur 9.12,sod the Hdth esti$afny
Code,Sedco M32(.)7 Type of Roof
❑Yea ONO
Will the.applicant or tiro¢ din mcu tan All roofs shall be inspected prior to any roofing material being. "
pp wuipmem or devices which f
emit haurdoa.ir minaminmu.1 sn by ay A .Air Quulry Mmegemeu installed. If a roof is installed without first obtaining an inspection
°'`""" I agree to.remove all new material's for inspection. Applicant
Ye" ❑No understands and will comply.with'all non point source regulations.
1 hover she rearmm t re9u nu oder Chaps6.95ofthe if the
a omia IeeM& net) ode.Sari 1 O5, ad 25330.I to III fix Wt if the
0di dm nor u rt haveam m, et it is responsibilirymoelifY the acvpat '
f
the fibemen w c ..in net eta ort. 6 aeof.Cenifiate of Occup.«y.
I D Signature of Applicant- '..Date
Ow randamirm g n - Dau
All roof coverings to be Class"B"or better
OFFICE