00020054 (2) CITY OF CUPERTINO . - PERMIT NO.
BUILDING DIVISION PERMIT CONTRAGT0R` NFORMATION: 0,90 O 0.5
BUILDINGADDRESS: •.
IIEMTJ�i�' O/1/GY, IIlVe ' SANITARY NO. APPLICATIONS BMiITAlDATE
E•..A/6),077 6 9;YT, V2V/V
-,64 C� NIC CONTROL N'
ARCNHITECT/F.NcI 5 _ 785-
' J� ' J _
—84G— Bu[DMc reRMrf INFQ
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LICENSED CON MC10R'S DECLARATION ` .•
O z_ 1 hereby all ther 1 an licensed under provisions of Chapter 9(commencing n Job Description..-
f;,:� with nasion]000)ofDivision3ofNeBmimseantl Rofeationt Cade svd mylicenui, - -
LieuenceC�ela`ed = 73�
m 3 u.y Date convenor
^�O ARCHrfECTS DECLARATION
yin} I unaennnd my plans shell W uud u public records
OO
e
Licensed Profesemnel -
uyi_ I OWNER-BUB.DER DE CLAMTION
1 hueAffirm Net 1 uemp,from the Contnctoficence LiLew for the •-
' ��❑ following rcsaoce n.(Semon]031.513,Busivse and Profeesione Cape:Any cityor coumy � '
m which n luims a permit no Winner;Wer,improve,demolish,or mplk any suucmrcS Ft Floor Area - - V 1 ation ISI
prior to its ismence,elm requimt the applicmtfor Inch pemdno fiileesignedsmtcment - q' /.'3/7]7
Nat he is liceaed pontoon N the provisions of the Conmm,a'I Licenw law(Chapar 9 - �DO• (J(/ +`I
(commencing with Stemen]000)of LiMsion 3 ofthe Burins and Profesaioa Code)or
IMt he is emmpt therefrom and dor bait for Ne alleged exemption,Any violation of APN Nu�ber. - - Occupancy.Type �.
S.mod7031.5 by any appOcot for a panni,mbjmb the apelicanne a civil Ceensty,of
am mon No five hundred dollen(5500).
❑I,amowmrofN Xopeny,mmyemploymawiNwegesus irsolacompensadon, Required Inspections
will do Ne wok,and the muctu a is not imMedoroffered farsale(Sm.7e44,11mounts
and Profeuions Cade:The Cmmactor'e License law done m,apply to an owrcr of
property,who builds or improves thereon,and who does such wok himself or through
his own employees,provided Net•such improvements arc not intended or offered for t• '
seleAfhowmr.the Wildin mimpr r;cmismMwiNinaneye ofcompletMda,
•owner-Wilder will him the burden of proving that he did not Wild or improve for pun-
pose of Bele.).
1,an owner of the Property,em eadumivelY converting with licensed emitter.ro - r
onswq the projmt(Sec.]044,Busicase and Professions Cade)The Commies W -
come law done not apply to an owner of ph puny who Wild,or finumme thereon,and
who contracts for'euch projects with a mureco s)licensed pursuant to Ne Convectors
Licenw law.
❑l an exempt under Sm. ,B&PC for Nis on
Owner Data
WORKER'S COMPENSATION DECLARATION, t ®�
1 hereby ePorm under penalty of perjury one of do following declantiom:
❑I haveod will meimem.Cenificine ofooment an selfdnsunforWorker'sCompen-
.. mtion.es provided for by Seeman 3700 of the Labor Code,for the pmfumme.of the ,' at
11��jjddrrwhim Nis penton is issued. 0111
@arhave sal will muinum Writer's Compensation Insurance,a required by Section -
3](si tabu Code.for Neperfmmance of the work For which this permit is mmed.
C.1 m1�gCynpep�ngn3pmfepq mn od PalieY^umh���'�QS
Csrtiee rfi TE FU�VLJ Policy No.: �T '
CERTIFICATE OF EXEMPTION FROM WORKERS' - -
COMPENSATIONINSURANCE
(This mttim need not Wcomple�ifthe perom is torose hundred dollart(S 100) t. '
or lea.) +
I employ
my dor in the any monnereofthewuk for which Nis ine Working,
Co shill '
Am employ any Canon in any manner so a no became subject ro the Waken'Compen- t '
p
te
Laws of California.Da
Apli
Appliaanl < ,
NOTICE TO APPLICANT:If,afler making Nis artificers of Exemption,you shouts
become subjceno Ne Winton,8 Compensation visions of me bar
Le Cade ou must
P^^ Pro
.r
s
Forthwith cam 1 with such rovisiona or Nis .it P Y C _ P' small be domed revoked. . .
CON
SON
LENDING AGENCY
I hnbydRmi Na them,
isac ctlo^Icnding agency
for the perfomunce of
Ne work Far which this Ceron is issued(Sm.109],Civ.CJ� - • l� _
,
[� Lenders Name
' ;(r IaMer'e Addrcsa .
W Q 1 certify thin I have rod this application and sate that she above Information is '
correct.I egme in ab
comply with all city and county ordinances and mile laws rin,to
z ' r
U 0 building conawcvon.and hereby suNorm repmee^mives of this city in upon the
above-memioned property for inspection puryn... '
W [� (We)egret m live,indemnify end keep harnleu the City of Cupertino against
Iimilities;judgmenm,caste and emprims which may in my way seems armuce said City
>i W in consequence of the granting of this permit. '
% APPLICANT UNDERSTANDS AN IIA,COMPLY WITH ALL NON-MINT
V z SOURCE RF.GULAT Ng.
r SignaumafApplicam oto - - Dale '• I - -J .�
HA D S MATERIALS DISCLOSURE
Will the epplicento um Wilding mcbpant store or handle hazardous material Re-roofs -
as defined by the Cupertino Municipal Cade,Chapter 9.12,ad the Hrnvh and Safety `
Cady,Sami.25532(a)] // Type of Roof
❑Yes IQtda
Will the applicant or form Wilding occupant use equipment ordcvims which . All roofs shall be inspeeted'prior to any roofingbeing'
material
aot rt haadouc an conumitwts al definW by the Bay Arm Ab Quality Managcmcnt installed. If a roof is Installed without first obtaining an inspection
❑Yes Tag Applicant
$( ree,to remove all new materials for inspection. Applica
l
I M1eva read the haaadmt maenads understands,and will com I ith all non point source regpulations.
re,M33 an V55 Chapter that Calle - P p
furor Health B Scurry Code, a cmc ]Shen,25533 and 25514.1 i naemyth that if the
huthengdorsnarts yuch hest aththao is mace of4biliry in notify the occupant /7 / v
of Nr ryuvemenv yn�ch must mpnoroieauence orfs Cenifimv of Li //(/ ,
owMrarap Z Signature of Applicant Date '
Da
roof coverings to be Class"B"or better
OFFICE
` - as
l •