00020181 • CITY OF CUPERTINO - y PERMIT NO. /
BUILDING DIVISION PERMIT- f CONTRACTOR INFORMATI N: V,�Q�
RUILDINGADDRPSS: + Tp /,^ 25_
;1 11 -7
1 -77 �'/•� �f ♦A bq io1 v �04,� La�• Xr /`N— % y �� SANITARY NO. APPICCATIOONN SUBMITTAL DATE
OWN 'S KJ CaVLJ NIC •�yi�/�yCONIROLe O .•
ARCHITEC'1'IENGINF.ER - - s 4 BULGING PERMIT INFQ
qe00
'o LICENSED CONTRACfOR'S DECLARATION
O.Z—n 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commenting Job Description
withsectton1t100)ofDly n3ofdmfu. as ab fysigyC astlmyliecusen_ - r
— in full farce end e0cn MAX 1j
Q 6 V eese 1.10.Y V / t �•
3 0 o, D.a� lnc /✓PC t/ ✓��LLC,� I, -
F�.O g Co.ARCHITECTS'DECLA O ^
Tory $
1 undenniid my pWs shall W us i u public records .
a a O Licensed RofesaiosW •• '
OWNER-BUILDER DECLARATION
C z a 1 hereby aRrre that 1 am exempt from the Contraztor's License law fa the
S G folluetag rcaaon.(Suns.7031.5,Bmitrcs.and Professions Code:A,city or..at,,
WCC which sorption a pemit m cam .,alter,improve.demolish,m repair any svucone - ^
3 m S Floor r Valuation,
prior to issuance,also requiaatM applicant for peztdttp fit eeaigrcd seatnent .3 /1 O q '
(commencing
comma liuuW punuannmhe pmvisiansof doe Co nu—.w-cenaldw(CMpter9
(tat be is xtM,therefon rom and th Isasi,on3of al Bu.eged exeendon Any
Cade?or - - Y -
That he is 31.5 b therefrom and fine burs for be ctsdue exemption t.Any violation of _APIA• um ter - Occupancy Type
Section then by any applicant doll rut v permit die applicant to e civil peu17 of
"nor mote Nan Ove hundred doltars y mpl.
❑L ore ownerk,the d ostrs�Y.m my employ«:wire wag for s d.r Sale canpem,dan, Required Inspections
will do he fesuctk,and s: he Cor is tot it Limmetended Law ed dos not k(See.o an owner
of
and to,w eau Cade:The eves dcmrs,send Ido s such
not apply himself lf owmr gh
his o ny who buil.,or wided 6 thereon, pr who dare such wok dlora through
his own employees;provided IEet such improvements sold s as nor inar.fc a omead for -
ade.If,howevcq the building bur en of mens re sold did but
Wild r in mo letforpu e
owa m'sam') will have the burden of proving Iden M1e did nm build a impfiave for pun-
pars
co I,ore mvwr of the(Sm.
Business ealus and convecting with licensed convectors m '
..L da es mo ($ore 1 an owner
ofand Pmlest he ds or
The n.tnerem,I.J.
cense law dcea nal applyje ts owner of propenY who builds or improves thereon,end
whotense Law.far such projeets with a conlndw(0licensed purivanuo the Conuactale t•
i
License Lew.•'
❑Iamaemqundu See. - ,BRPCfmthisrcuon
Owner Dee �/ ,
WORKER'SCO, I pejuTION DECLARATION
Thereby al mande.erpaneByorp Comary n<ofthe followIm Woref.C.cts. r •/ '
]on,a,ora will remoteln a erre 37ea of dm L.In Cotim,wrt for WokeYe Cotnpem
cation,m provided(pa by Secure issued.3100 of fila Lebon Cede,(bathe pertotmawe of the
work have
which this parotic is issued. '
❑1 nave end will maintain Wak"D mon o"Mtion Insurance,u required by section:
3100of0m Labor Codafor pertomtartceoftheweakfes hichthispatnitisiss '
My Wo qt � r "�,,,rg�1-
Cavite sOJ n h IySgl}gg,GY9 t .
CERTIFICATE OF E E' n NN'YF�R�OM WORKERS' "
COMPENSATION INSURANCE •1 '
(Thmsecti /r ehutdrN dollen 5100)
or Ices.) �Vpt��} �'t�t^/t�J''�r Q1 y -
Icenifylhe ,hsps am� .p.dite,eoh l6r'rM1ich�,mart,minued,(I shall .•
.at employ any person in any manor w as m Wcnme subj.In the Worl en'Conesm.
union law,alcabloortm Dam-
Apple.,
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should' '-
become subject to the Worker's Compensation previsions of the tabor Cade,you must
forthwith comply with inch provisions or this permit shell W domed revoked.
,O Q IheabY CONSTRUCTION LENDING AGENCY-, -
affirmlhulhemisaconm=dmlendingegencyfatWpertomsemeof
the work for which this permit is issued(Sec.3091,Civ.CJ
a Lender"Name ..
Lender's Address
W 1 rorty that 1 have read this appliestime and we that use above infortanum is
96 5 z comfit.I ague to comply with ell city and county mAinener.a i sue laws sluing to
V 0 building construction.and hereby eathonte n,msenwives of tido city to enter upon the
above-mentioned property for inspection purposes.
fin, H (We)agree to save,indemnify and keep hamltes the City of Calamine against .•. • .
O (.,) babik9ex:judgments,coon and expenses which may in any way seems against said City
} W in comoccance of the granting of Nis permit. '
[� Qa APPIAEANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT "
U Z SOI EGOLATIO'S..
— -3
SignawaurApNicamu Comem l Dan Q�.
HAZARDOUS MATERIALS DISCLOSURI!
Will the applicant or future Wilding mcupem store or handle hazardous ammml Re-roofs - 'an defined by the Cuperim.Municipal Code.Chapter 9.12,aul the Health and Subtly
Code,Sethon25532(n? Type of Roof
❑Yea *.
Will filer applicant orfums Wilding acupant era<quipmcm or devices which
All roofs shall be inspected prior to any roofing,•material being "
it becoodrom irtommeninams as defined by the Be,Awe Air Quality Manegemem installed. If a roof is installed without first obtaining an inspection
strict? I agree to remove all new materials for inspection. Applicant
❑Y<s [�10 d
1 have read the hazardous sfwenals requirements under C,apsa 695 at Cali. un erstands and will comply with all 'non point source regulations.
tomo Sint&Safety Code,Sections 25W5,25533 and M536.I undarxuu d that if the
Wild' ommxcurmtlly eatenanl,llwitis myres nubi�ashlytheraeu,sum
of e e is t W nm Pea to few Cert t of OttuPaw
Signature of Applicant Date
Owner or eutM1onud
Dam
All roof coverings to be.Class."B••or better
OFFICE