00030214 - . A - + ��ryryrQ- ♦ry hyo . 11
` BUILDING DIVISION _. CON y g�ACTV R D N0.
CITY OF,CUPER_TING t 'I1�IF'OR1yIATIQN PERMIT -
• ' PERMIT `
(-' BUILDING ADDRESS: - •�
WKI
� "' 1.�•��� r S.N/C 'CONTE DATE
CA'1 ANIPARYNO:' APPLICATION SUBM
i? 'S NAME'. 0//.,..�I
TON,,: 1 .� o .eP5 :
.
t tCHI 'CT/ENGINEER C, B PERMIT P
m 0 U0 SSOCiar�S CA U c't '6q z
[- LICENSED CONTRACTORS DECLARATION
z 0= 1 hereby affm that Tam licensi:A oder pmvss]ons of Chapter9(cmunw mpg Job Description' ,
I-w with Section T000).(Dsv,smn 3 ofthe Bussass and Pmfde/siyonxC dmy lice sus . . - ``.• t �ry�
�a < 'n full fora mdeRcct. ¢¢.. .., . V �i� �v A,D ../J��,3.� 477 -e
Date sr�—a=Lied— , IN U/{..' /�TIW/V!'T/`ONI
gr DmellfcontractorAK�HAION /j -
I.; ' s1 underehnd rey Pla a shallli c sed aaEp bliicc recorgh '• •"�D� �f '" _ 7' �O �
i e o z IacenaM Professional. - • +• `. ,•
v, + OWNER-WILDER DECLARATION
k G 1 hereby affirm that I am exempt from the Contractors License' Law fix,the + s
5 O
'llowing usixon(Section M3 VSB si mss and Professions Cade Any city Or county '
w o .whin rx,mmos.,annot to c Iruct. leer.imPmr[.demolisn pm any sbumme Sq Et.Floor^Area _ Valuation
a3 Pd to it d- reqce, ms this applicant for such parous mflee geed ammmrnt
that he is licensed pursianrto he Provisions of the Contractors License Law(Chapter 9
(CommerRmg With S0.460]OOD)Of Division 3ofthe Barletta and Predfico sCode)or PN umber - Occupy ane e
• e.
that be n exempt therefrom and he bests for he alleged axe p o A"y SmInsu n of -` F �p
`Section 70313 by any appncaai for a pends subjecb rhe applicant to.civil penalty, f ��3-008not more can rive hundred dollen($300)
❑1 as owner of the propenY•or mY e!nPloyem wile wages ae heir sol.......do.. - "'Required Inspections ., s
will doth.work Ondh mmh rcss nornmeMM moffeeM for sal.(Sa.]O44,Bu' es _ s.
Slid Profeeaiom Code The Contractors Lt...Law does am apply m an owner of
S
prnp[ny who builds a tmpmve.thanigni,ard alsocke,such worithismstfmidarough
his own employees.Provided that h improvements com not intendedinfr red for,
sale If,however he building improvement ss ldwhnooe year fcomplet on,the r... T -
ownttWildtt will have the burden fMovi.,that heddnot Wild Or smprxuva-fin par
M foal )
❑ �kfs,
I anti of h<property, -exclusively IY convactin6 with licensed conu.ctnn m
construct the project(Sec 7(44 Ba"nes.and Irmficagona Code)The Contractors 4-
can. la does t apply to an owner of pcny who builds r impr n h on,and
whocontractsfor such pmJ wine on mogs)licenaedptl hh Conrictri s y, a ! h / , „
'Lice Law. 41 .
on - B&PCto,
this�retro z. s
D RL O Pew»•....rV d` .,
r. NEE S COMPED ECLARADON
1 hereby sffirm under patchy of perlary one of he follow ng decieraU ata • h f t d r4 I�,i t
the d Il mainwne C[rtlfiCam ofComrntto mlfms rtf Work Compen- A /t '`,`1 I {
"am,a.Provided for by S edon 3700 of the Labor Code for the Performance Of he
work hichhls Permit issued, e ° ban
have Slid will maintainWork 's Compensation 1 uranc req ted by Section 3 0 2000
'A
I ofthe tabor Cods,to h performance ofthe workf h h this Permit is issued ( MAR - --
M Works,r/�Q rand lamer dPol' q pq _�L q s .. �� '�•*w 1
Calder��AA+--e.a a a� ' Policy NoY»T 1'J-VI "1� - , Iy `
.CERI . COMPENSATION INSURANCEATE OF EXEMPTION FROM ORKERS s + By
y, (Tit 'eetnnn dm bectmpletMfh penitis foronenpnded doll - (3100) _ AT`-- •- •-"-"t^+ -
mle ) - I. ,MAR'; , 2000 elf .
Y mfy that m thePerformance ofhe tkf whichh pe t d Lind] 4
not employ any Person in any manner so e t bee subject t the Workers''C pe r 1 s. t i J i 1�'•i,
,sato Laws f Ccifomm Det' �y A
Applicant'
NOTICE TO APPLICANT If.iii ter making this Certificate of E pd n you should - .w.,:
Isme ub3ect to the Workers Compensation provisions of the LObb Cade.you m s
forshwih comply wit such pnovsasans or hrs,permu shell be dxmed rtvokM. `
p..
CONSTRUCTION LENDING AGENCY -
0'O • IA rcby affirm Otic here isaconswcuon lending egeocytortheperforman of
. rZ., the work for which hi permit is issued(Sec,3041,CO,Q 0
,r.
LendersName
Lu der Address
W,Q 1lenity that I have read his application and amts that he gbove infommtion Is
correct I agree to comply wish all city end county ordinances and state laws relating we
budding construction and hereby Schools representatives of this city m enter upon he
V C OmOc-meMoned mopetry for impulsion P'"PreeS.`, , • ` -
L. ;: (We)agree to save,indemnify and ker,humlws the City,of Cupertino Iauml - .v "
L) liabilities judgments,loam end exparsee hick maymany way accme agmnst said City ,
in consequence ofhe ata g of is pe 1.
'til Qs APPI(CANT UNDERSTAN S AI U W lCOMPLY WITH ALLNONI'OINT. - L t'' • ' " ,.��'O q /_
IONS.: O[/
a i8 ore ol'Ap UCnntiactor -- .-. Dare- ,,. .! •t '
w HAZARDOUS MATERIALS DISCLOSURE - , -
Willheapplment rf mit bolding Ocuupem slnrc or handl hazertlous meRna] Re-roofti .•
as defined by the Cupen o Municipal Code.Chapter 912,and h H alh and Safety �' F
Cm Section 25532(.) /, 'r Type of Root
Will the pPlceniorfuturcbuilding pant use eq p t ae ire, mc„ All roofs shall be,inspected prior to any roofing material,being `
inn havudon it c0 mm ants as d[fyt dbyh Bay,AnotAl Quel toddy ManaQ ent installed. If a roof is installed,without`first obtaining an inspection
" Y—rsA/ I a rise to remov all e materials for inspection. Applicant
❑Y g
understands'andll oro ly w[th all non pomt 'source regulations.,
I base red dais hvazdous 'c, turemeno.underC"Pler 6.93 Of the Cali-
fomm H lth A,S aimy C Sccu 25 5 25533 d 15534 1 understand thin if t n
B currc Oy has I s m it is in,responsibility to notify the Occupant __3' 30'��✓ ,
:oft rcymnon, SI m Mo w,eauanceofaCenificatea Occup _ e
_ - ,t� O Sig attire of Appbcan[ Date -
.Own o auto led again Dare '* '
�^ All roof coverings to-be Class"B"or better
OFFICE
CITY OF CUPERTINOq�?"�'f 1� y���(r'.xr*I�^t++�'{'' " + *st;' ',x.'xkt>+a; PERMIT NO
BUILDING DIVISION PER
BUILDING ADDRESS 1 J
�/u/�� SANITARY NO. APPLICATION SUM ITTALUAT
OWNER'''S NAME: '^ / • ! J J
• 11';r .7 Zj 1( i'il' rr ' NIC F..CONTROL#
L
]ONE _'. . n; a,`., s C r'+,A I .t='t G- t f rs � •�.L i- � ❑ � �U
ARClIITECfIF.NGINEER 1t�f,:`� ��1 I 1 �. ?_ ',*#.ct ,&'"r`6BULDING PBRMrr INFO
41,L" I
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NOTES
o=� Job Description '
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Sq. Ft.Floor Area Valuation
APN Ni fniber ccu panty Type
7L/ r 6:3
Required Inspections
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MAR 3 0 2000
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Re-roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
I agree to remove all new,materials for inspection. Applicant
understands and will c'pm ly with all non point source regulations.
Signature 6TApplicant Date
All roof coverings to be Class"B”or better
APPLICANT'S POSTING COPY