00050088 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0th 0 50 o 8 g
BUILDING ADDRESS:
�/ s't�V� t �. 1r SANI'1'AHY NO, AI'PLICATI NSUB hfc? DAT
\ OWNER'S NAME: NIC CONTROLM
�TL/�9'r-G LW ❑
ARCHITECrfENGINI:ER �—%'^— j �• / usT BULDING PERMIT INFO
Mffi0
Lie-# Re/ 4219.
~R i LICENSEDCONrRACTOR'S DECLARATION lob Description
Oz—C 1 hamby dfrm Nu 1 w llbmsed uMa provisions of Chapter 9(cammcroing p
f-w wiNSmtion]0110)ofDivision3oft Business, Professions Cade,W.,I.nee is
�ydG io full forc�ey,MCRe •� 3 0
0,U
iO License Cl asx Lica
u 3 u to Data conuac it Nl
Fu.O RCI(ITECr'S DECLARATON T�_
u Ij,g uMerda;//y Clam shill h u Public meads `C'+
ce 6O+p --_Li
6 6 p K �amed Pm cuumnal
OWNER-BMDER DECLARATION
l=z< 1 hereby•Rrm dial I am exempt from the Cantmctors License Lew for the
s ff❑ following rte .(Section]031.5.Business IntelPbafeariom Collet:AnY city a wumy
3 which mil part to construct,ition,Improve,demolish,mrepairany associate Sq. Ft. Floor Area Valuation
rt
prioo its imitation.iso m9uims the applicant for such permit file a signed statement 70, AA
Nat he is licensed pumumuu the provisiom of Pe Contributes License Law(Chapter 9 (f(' V U
(commencing with Smdon7")of Division 3 of the BuzimuaM Profeuiom Cade)a pN Number OccupancyType
N,1 be is exempt acfmmb rise basis for the alleged exemption.Any violation of YP
Section 7031.5 by any epplicam for.pemit,uh*I,the.Whcam to.civil pemlry of ^ '�O0-7 1Y
not mom Nen rive hundred dollen(5500).
1,axawn=refthcproperty,a,ser=mplayee•withw.gerasNdmmeeampenssdon, Required Inspections
will dothc workemiction,,and the eis not intended oroR=m i for side(Ser.7(N44.Business
ad professions Codc:The Contractor License Law doer not apply to an owner m
progeny sued builds or unclad that
t such i tad who don such wed dad or
m dumeb
his own empty the
provided Nat such improvements are Imt intended a alRred for
We.If,however•the building m improvement is sold w id min a year of mm ve for de
ownewW ildcr will have the When of proving dial he did not Wild or improve(m pur-
pou W.de.).
1,as t the of the Sm.7 areexclusivelysinend containing with licemed cunuamon i-
construct de projal(Ser.]064,Business and profession Cade:)The Cmaeclors Li-
Lima.
i-
Lew tiros ren vpply m m owntt o(peopeny sub Wildx m improve Nneon,end
Limafor each projau with abonv,<mr(s)licen,ed Punwntmthe CanvutN.
Licen.LLeaw.
1.m exempt under Sm. .B d:P C for this on '
Owns Dam
WORKER'S COMPENSATION DECLARATION
L hereby emrm undo penalty of perjury one of the following dmlamtiau:
I have and will maintain a Certificate of Consent to self-Imum for Workers Counter-
W ice,as provided for by Section 3700 of Ne Labor Code.for the pefomunce of the 1
.it(or which this permit is issued. X
❑I have and will maintain Worker,Compensation Insurance,as ox rind by Smile. Q
37Wof the Labor Cab,fmthe pcdarmance of Ne wart for which this permit is issued. �I
My Worker1 Com seise Insurance<,rtin and Policy�nu�her��'y
Cerner:`Asq n�'[.[rk Policy firy Cj(,�_-,� 7
CERTIFlC COMPENSATION
�PTIATIONI NFROM W KERS'
Ct becom'SATION INSURANCE /
(Thio unmanned rot becomplemdifthc permit is faone hundred tidier(5100)
or lots.)
I employ
any drown I.i erforman, of a.orkbac for me,which this permit i,ars,Ci l shall
par.
ret empty any Canon in my manner m n m hecone subject m the Wohen'Compere /
suition Laws of California.Dam O
Applicant O
NOTIorCE TO APPLICANT:if.wafter making this Certificate a of LaborBon.you ushould
most
hernia h comply
din Workers Compensation provisions steal of the LRWr Cade,. man
funM1wiN comply with such provisions or Nis permiuhellWdamed invoked. ,
CONSTRUCTION LENDING AGENCY
Q Q I hereby affirm NU Nem is a comuucdon Incitingegeney for the perfmm.nce of
Z gas work for which Nis panic is issued(San.3097,Civ.C.)
FC4 Lender,Name `
� ' 1<ndee,Address
WI cutify Nu I have read this apphanimi and sum Nal the.hove information is
1 Geormal.l spin,m comply with all city and eoumy ordirri arvd ste talaws main,In
Z Wildinecoetmcdon,and hereby anthem.repruenutivaf of this city to tier upon to
V Q above-mentioned property for Iowa--purposes.
W E. (We)sgme In save,indemnify and keep harmless the City of Cupertino agdmt
(, li•biliti,judgmenu,costs and expense.which may in any wry moue agdnn said City
} Csi in coosegYence of the granting of Nis permit.
'r 1 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONd'OINT
� s<I REcuLAT s.
Signature fApphc.miU.amwwc / Data
HAZARDOUS MATERIALS DISCLOSURE
Will dev,finsito,fmwc budding compant It.01 handle haxudou,marcid Re-roofs
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety Type of Roof
Cade.Section 25533(.)7 ^a YP
C Ye. t�N
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
lhrea,dau,tr mnuminm�fied by de Bay Am.AG Quality Management installed. If a roof is installed without first obtaining an inspection
-strbo I a ree to remove all new materials for inspection. Applicant .
❑Yes
I have mad N=huardous mamdd.m9uimmenu under Chapter 6.95 of Nc Cdi understands and will comply with all non point source regulations.
fords Health Ar Safety Code.Sadao 25505,35533 rand 755X.1 uMalud dial if the ,
building,ops ad currently have a mount.that it is my reapomiably W wily din^aupant
ofd rtrnu wN 1be tpn wnoa of.�aofo ,xi
aDt7U'O Signature of Applicant Date
Owner ear euthorired agent Data '
All roof coverings to be Class"B"or better
OFFICE