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00040039 CITY OF CUPERTINO PERMITNO. BUILDING DIVISION PERMIT CONTRACTOR INFORMATIO,N:: OD f L w 3 BUILDING ADDRESS: J p ) `l '�/SL/kQr ��(/T� t--y�ISTr SANITARY NO. APPLICATION SUBMnTA DATE j/I. �'' NAM , r ^� ©� l -. 2-766 op7 66 /S,C_oTt RIM, NIC CONTROL. I I'H0162:�;,lql cJahT C�CI�L'Q, (?A. 9,5105-6 ❑ i, HCHITEC MISGINEER log -/Z7- Zyzb BOLDING PERMIT INFO °� Gr c 7Ar 336-61,1 I. Baa N j LICENSED CONTRACTOR'S DECLARATION z O v— I hereby alarm that 1 am licensed under provisions of CTupler 9(commencing Job Description F=r�: with Sdtkn]OW)af Division3of rhe Buainasand Pmlcoions Code.atdmYliamei+ t� ') ' 2�7� in full force and<rtua. ��. Zrl%,34AII "1 W Pt,4,PaA,tror+\S CX4WCS In YY%AS4?r Od Liceumcku uc.. a N Da —Y?9—Co am $g7i/KaWroS 7 7oTat) r no pllPrnf/ons o� S>�uGTGc/a� u.y ARCHITECTS DECLARA D XAS-W I eA4 Ufa I undentaral my plana shall W used u public rccdda wroo vwhe>J dDwwtsd u reecle , C1 nc z licaudPmkssinrw 11 {`oL ray 'R+'W ae4;,C"IAYe,S . neat! 4.;a.olegend to I u OWNER-BUILDER DECLARATION awe / t:=x a i hereby alarm that 1 am exempt item the Contrecio/s License Law fm tW n`J4R, �F C following nosed.(Section]031.5.Business and Professions Code:Any city or county h' uc 3 m which occulta a Permit re manybor,alter,improve,demolish,or tcialb any structure Sq. FL Floor Area Valuation prim tons issuance.also ma,fres Ne applicant(branch permit m file a signed sue,m e, G Net he in licensed pursuant o the provisions of the Conrtserars Create Law(Chapter 9 (commencing wish Seen..7")of Dwki n 3 of the Business and Pmressiana Cohn)or APN NbOccupancy Wt he is exempt therefrom and the basis for do alleged exemption.Any vialaren Number ane of ) P Y Type Section 7031.5 by any a,diaut for a permit subjects the applicant a civil pcndty of a b _ q-7-016 6 pt mom than five hundred dollars($500). I..saw.endrNeptoPartr.armr<mgaya.wiNw.genaNeir.alecamPain.timi, Required Inspections w ill dal Ne west.and she structure i,oar intended m offeree fm ulc(Sex.7000.B usinns and Poofeminns Code:The Contractor's License Law does not apply to an everter ar property who builds or improve.Nesse eon. d who doe.such wort himself or through his we employee,,provided And such improvements am era intended or effected for WO.If,how<ven Oe,building or improvement is sold within doe yearaf completion.Ne erne,-buudar win have the bunker orproving that M did not Wild m improve for qts. you of scler). BUSINESS 1.u owrcr o(Ne property,am surras and!convscun8 wish:)The Ccanvamon i- 1.consat t a e r of th(Sm. rt0 a Business and Prokuiom Code:)TW d count m'a t cense Isw alms nm apply m an ith a of pmperay wce Wilda d improves dvi<om and who cantruts for such gdlats wish acdntnetar(s)licensed purswnt to the Coniruldla ucase .w. ❑lam exemptunder Sss. .B&PCfm thisrea+un ��� ��� Owner Dam WORKER'S COMPENSATION DECLARATION I hereby alarm undmr penalty of perjury one of the following Worker Cor Ihave ad will forbyneCmi3700 of Co.,Labor Code.sus for WdkeriCompeere ��� union,r provided for mi Section 3]00 of the Labor Code.for the performance of the ort for anal Nis permit is issued. ❑i have std will mdnuin Wands Compensation firsonwork fou hi h his menu issued. My W.the IsWr Cede,for Insurance n uranc ma ro of the wwk fou caber this permit u issued. My Workdx Compensation TE OF E ORim and Polley number ER Caroms. Policy No: CERTIFICATE OF COMPENSATION N FROM WORKERS' COMPENSATION INSURANCE (This section need not M completed mit if the perix(atone hundred dollen(5100) or Iran') 1 certify that in de,performare,e of dv week for which this person is bound.I shall not employ any .on in any manner ys to o '�Issuo the Wankers Co.,.. / union Laws of Celift�aj� •+��c'�e� ' Applicant NOTICE TO APPI.IC NS': a is nificav of Exctnption,you should hccome subj of m toe Werliu.Compensation provisions Of the Lebon Cade,you must fmthwith comply with such provisions on this permitadult W deemed ravoked. CONSTRUCTION LENDING AGENCY QI hereby septum Nm there is a construction lending agency fm the Perfermuve of z the work for which this permit is issued(Sec.3097,Co.C.) lend<f,Name ((i > Leedda Addre k7 I cenify No 1 have read this application am.tam that the ayes.information is P. a cones'.I agree to comply with JI city sed county ordinances and sura laws rebeing to Z) Z buildingconsvuction,and hereby arthodr<mpresentatives of this city to envy.pun the U abosmommimmd property for impatien purposes. (We)agree to save,indemnify and kap banniess the City of Cupertino against U Iiabllitin,judgme.v,m,tsand eapernen which may in any way accme against said City } W in con.eeume,oftha granting of Nis phot. Ir 96 APPLICANT UNDBR. D XS AN11.1,COMPLY WITN ALI.NON-POINT C.) Z SouRCE NtjyB.A r A V-6 . si,..&Aaf AWlic ifC�or �JDam � HAZARDOUS MATERIALS DISCLOSURE Will deapplianwrfumoc Wilding nccupanl.tore or handle haaadous nuudd Re-roofs as d<Eie,d by the Cupertino Municipal Cade.Chapter 9.12,and the Hath real Safety Cede,Section Type of Roof 2553200] YP O Yen *kNo I' Will Na applicantmr`umN Wilding oceupantuse muipm<mordevices which All roofs shall be inspected prior to any roofing material being i . alit„. .airconsent..uasdsfinedbyde,8,Me.AilQualityManagement installed. If a roof is Installed without first obtaining an inspection sr sol I agree to remove all new materials for inspection. Applicant I have~ than haaardms daudal,on,dir<mmnts aider Chapter 6.95 dfthe Cali. understands and will comply with all non point source regulations. forma Hader&Safety Code,Sections 25505, 5533 and 25334.I undentsnd that if the - WildingdosnalcutocntiYhavc Lthar myocspoaibilitymmtifY thcomupmt of the vyuirtmenly�lich sand po usuame of a Canilm10 f tacuww�''Y. �/ i y,.� D4 Signature of Applicant Date Owmr or sash r +�_ All roof coverings to be Class"B"or better OFFICE