00030219OFFICE
v- BUILDING DIVISION'v PERMIT
CONTRACTOR,INEORMATION:
r/f I
v
BUILDING ADDRESS:
/n n'019
SANI'IAHY NO.
A LIGATIONS Bb AL DAT!
U 2
1
�'i"V�'
VVI\S1\
3 3J- 0o
OS 'ER'S N ME:
\L l
N/C
CONTROL#
�aa 4X`L�
El
C
PITO C
�^
_,2C6
\��
15
ARCIIITIiC'I'/lith ON ER��/
IULDINO PERMIT INTO ±.
/yy,�././J/
�Ovo
Q00
NU0
o :J
o S = C
LICENSED CONTRACTOR'. DECLARATION
I hertby.Birm shat i am liccnw,d under visions of Clupar 9 (eommerci
- Job Description
F=C-1
wiNSasiont0)(BOM,ivision JofWe Butincv and Pofcwiom Cede. ud mY liecnse is
,
%o ma
in full farce and effect
useassaw. ere.#
Dote Conaecmr
/ /L
DECLARATION
de st n e used as public records
O gITECTS
/ J
� F
v S:2O
ens d o uio
`�ti1 2
M
ER-BIRLDER DECLARATION
I- >. >•
O
1 bcrtby eRmr t 1 un exempt from she Cmuretchri License Law for the
Y
following mann. (Sect' n M31.5, Busircss eM Profeuium Cede: My city W county
$ I"t. FIOOr Area
qq/•
Va�UatlOn
C%
,u _ $
which requires a permit re conswot eller, improve, demolish, or rtpsir any samemrt
pdW m its is ..sce, aisc cultural the applicant for such permit to Eta signed statement
sut to the provisions of she CWNantor's Licanse Law (CTugrs9
shn he is licensed ptuan
.i-
So'9J
(comentraing wish Section9000)of Division 3 of she Buaineas and Proteuien Code) Or
APN Number
Occupancy Type
Nat he is narcosis efrom W the basis fee she alleged exemption. Any violation of
9031.5 by for the -Mile— or a civil of
�7! e� O ff_
-
Section my applicant a pemtiuvbjecto Pena1tY
Qt more Nen Ave WMred dollen (SARA.
1. as owner cfda property. or my employer. with wall as Ncirsole...... do.,
Required Inspections
will do the work, and shesvucwre is not intended W offered for We (Set 9014. Busimw
and Profeviom Cede: The Cmautm's Linnse law does cant apply m an owmr of
property who Wilda W improves shereon, W who clan such week himself W though
his own employees, provided the improvements K such improvements sot intended W offmad for
We. If, however, Ne- building in improvement Is sold within one year of completion, the
ownsr-builder will have she burden of proving that he did not build W improve for pus-
/
pow, of role.).
a1Jf///
owner of the property, sexclusively contracting with licensed constituent to
h in en
comtmct the project (Sec. 9814. Busircss and Profewiom Code:) The Cmro ke- Li-
as
cel Iaw does tet apply to an owner of property who Wilda or impresses thereon, and
/
who connacts for ouch projects wish. conbanee(a) licensed punumt m the Convector"
10
Wecnw, Law.
�/ Q
1 em exempt under SM. . B h P C for this maven
\
Owner Date
WORRFR'S COMPENSATION DECLARATION
1 hereby affiM under penalty of perjury Dire of the fallowing declarations:
❑1Mve and will maintainessni w,lGi, fee Warkda Compete
Label far
worn, as provided for by Section 3900 of she LeWr Code, for she per/eemanW of the
37M of
work fee which thispermit is inkel
1 have and will Section
ms
Workcra Compensation Wurvwhi
h pens n i
3200of ted Lather Code, fee she ptrfomance of she wart for which this permit is unwed.
ode, fon
Compensation Inwr.rcs carnetandy num4r ere:
No.:
Carries Policy No.:
Center:
CERTIFICATE GP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not bccmnPlned ifNe Permit is formic hundred dollen (5100)
W Ina)
I Nat in the work for which Nis permit is issued, I shall
any...peff.e.fthe
not employ ter person in any manrcr n v so become wblar m she weeten' Compel.
employ any st.1
inion Laws of Gli(omia. Dare
ant
NCE If, afar making this C of don, you should
NOTICE TO APPLICANT
NOTICE
the Labor Code, you mot
become object Workers cions o Labor
k
Comas. it provisions
•
or t b
forthwith comply with such provisions. or Nis permit steel be deemed revoked.
y it pro
CONSTRUC ION LENDING AGENCY
p
I hereby dfrm Nat Iberia is a conswedon lending agency for the performance of
'
the work for which this permit is issued (Sec. 3041, Civ. Q
(..s ti
Lender's Name
under', Address
(� >
asore at the above infomution Is
notify Nat I base send dill applicationnd N
{�I
Il z
C.I. I .gene to comply with all city and county ndwmes and ma laws relating to
building comsmcGon. and W cby euNniee represenativea of this city to enter upon the
U
above-mentioned property for inspection purpows.
LL Fy
(We) agree to save, indemnify and keep henmlexx Ne City of Cupertino against
-
(] C.7
liabilities, judgments. costs and expenses which may in any way meme against laid City
>, W
m consequence of Ne g{ran �rrg of this permit.
0.
APPLIC if TSIs; hi SAND WILLCOMPLY WITH AI. NONP INT
U z
SDU v If
of
. rgnat ppb t/ ter Data
NAi ODDS MATERIAIS DISCLOg RE
Re -roofs
ill Ne ePpl' or future Wilding rccupmrnncie handle hatandom mausid
in dcfrned by the Cupertino Municipal Code. Chapter 9.12, end the Hea1N and Safety
T e Of Roof
yP
Code, Section 25533(09
I]Yes
Will the applicant or future building Occupant use equipment or devices which
All roofs shall be inspected prior to any roofing material being
rich transitions as conealments in defined by the Bay Arra Air Quality Management
installed. If a roof is Installed without first obtaining an Inspection
""' Yes
oleualartyuirttrcnaurderChiparti95
I agree to remove all new materials for inspection. Applicant
g
with all non source regulations.
/
I IheverWNe a ftheeab-
IT
understands and will comply point
forma Heal fq ZS s 505. 255]3 end 25534. I olden thus if the
Wilding I hav an tthatitixmymxponslbi tymnnif theonupans
fsh t tonumm aC "at o
Signature of Applicant Date
client erg m Data
All roof coverings to be Class "B" or better
OFFICE