00050077 'CM OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTR OO 0 ,5-0 Q
BUILDING ADDRESS:
1 ((f_� t� �� SA ARY NO. APPLICATION SUBMITTTTAL�
� Dn�ATE
(OWNER' NAMIi: I` tOy��Cl• �• —V�
14 14 NIC CONTROL#
77 L/6
ARCHITECT/ENGINEER _ j dBULDINO PERMIT INFO
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Z ZO N_ LICENSED CONTRACTOR'S p DECLARATION
•Iion7 ).f Nall 3licensed under lidom.f 9(commeres
CZ z—� � # ob Description
F: with S forcea000)of Division3of du Bu.itrcv and Rofeuirm Cock.and
mylicenx is
in force and eRa V
' O U laanee Clev Lic.N -
�3 u�
Dem TS Ems
C O eJ ARCHITECTS DECLARATION J� /i• C,� -
g y lundenund mY Plem slWlWuxdv WElic serosal. ,{�,{7✓/
i a Iaccn.M f drevmnd
OWNER-BUILDER DECLARATION
< 1 hereby affirm rhe,I un exempt from she Connector'.lace..Lew for the
C following rasa..(Section 9031.5.Business and Profusion.Cods:Any,city or c...ly
�u $
which implies npttmir rouimwm,eller,improve.h perro.h,ore a sig ed .wcum S Ft. Floor Area V_ayI{pf1avy
— puohe is liuusrce,dEn to
the epides,of fortieth micenseanrdm¢mem q' UUv
drat he is licensed pursuant to Ne.f Division
of duehe Business
Caller Law(CWpta 9
(condtrcncin6 wish Sadon]OW)of Dlviairn J ofNe Banircu end Prrfeuiiw Cade)on
W,he is exempt rhcrefmm and the hadis fon the alleged exmptim.Any virlamen of 7/ APN bar ecu ncy Ty e
Section]031.5 by any whount ter a pemdt mbjecu the Whient to a civil pend,,of CiC(p
not mom Nen Eve hundred dollen DSM).
❑I,a .w.er nr n p.p ny,m my empinyx.wire w.g a E mein xle emnp n ears., Required Inspections
will Poorework,and :T he onsishoi License Lawdos..a(SEAQ##,manioc.
and PropProerty
whom Code:The C ed then r'.License law does na apply m lf owner gh
propmy wW Wild.or improved therm.,and whir,does such word,himself or through
his own employe.,provided trim xch i ent is sold .em m intended decrepitation,dation,for
We.If,howev wthebuildingEimprovement i.adwithint yeapowcfrpr.
neo-W.).will have Ute burden of proving cher he did not build..improve fon per.
.of
I.E owner of the Sm.7 and exclusively connecting CwithW licensed crnvxmts ro /��^
uricconstLa Nees Out(Sar o an BudE.and rry whe ona Code:)The Contmmf.U.
and Y
ecru law doe.Out apply m u owner of pmpmy wW W d p or improves Ne atrac and '
who mnLacafor such po)ecu wiNaconvardorta)Ikenud Wnuanlmtk Crntnao/e
Litt..Law.
El lam<xemptundersa. ,B@PCroc Nisrturn
wner D to
WORKER'S COMPENSATION DECLARATION
I hereby emrm under penalty of perjury We of are,following chowebon,
E C3 I have and will maximum eCernficau of Conxnuo sulf-insure fm W.heirs Comprn-
.00n,E providri for ni Sado.J]Op of du Labor Code.for the perfomume of the
for wNch Nls permit is i.9tKd.
wont have end will meinuin Wohcr'a C.mpenxu.n Insurance.h required by Nation
My W.drc Lab.GrNe,fW l e perfonnance of the wank for which this permit is issued.
Ca Wofaer'eC elpyon wQrte canis end Policy nu&am. .�p/i�,1/
Camcc ui Policy No.: WKFS' W
CRUll CATEOF EMPfIINN FROM WORKERS'
COMPENSATION
OMPONINSURANCE
(This axed..need rot treanplaemphOo d if the pend,is la orehuomcd dollen(Sl W)
role..) A" "
Iepetfonmemploy lunmm.a.i.nLwsoApplicantODCETONT:If,e0er meting.his Cenifinu of Exemption,yeti Should
heeome.bj..m Ne Woher.Compenudion ptoviciom of Ne labor Code,you muv
IoMwim ccmp,Y."xch ptovisiahs m Nia#candid srdl W domed rooked
Q CONSTRUCTION LENDING AGENCY
I ueubydfirm t pe Nem issued(Sm,
3n len ding agency for the perlotmmtt of — _
the work for which this pend,i9 ia.ued(Sar J09],Civ.CJ —`
[r Lendae Name
tenders Address
k7 0 1 cenifY o c i have sad thirty am county d cute that ire above infomuting is
7 Z cursed.I a mu to comply there all city and mums otdiruncn and sum hong relating the —
L.) p bWv.-gcononcd m,mY thereby amhodurepre.nvtivea of city to enter upon tW
above-(we)-,0 mope,for emenifd.n pury.xs.
[L F. (We)agree m nave,indemnify end keep
[V� V lAiPPLICAyIg'Alm9fe�nf)uE,Rremand e/ whic
h rh�uarymCity Cupertinosg
dmt
itirs,oayEcraeagdntaid City
;,w or cmi'lecoeof the gunnf)hispemdt.
STANDSANU WILL COMPLY till 111 ALL NON-POINT1�
no
, Jan-. S/i1�d0
si a Applic.Urn cmc -
HAZARDOUS MATERIALS DISCLOSURE
Wilby t e Cupert Or nosutureWildingMunicipal
odc,Chapter
9,12,handle Hea do and Safety Re-roofs
v defined by the Cupertino Municipl Cade.Chepmr 9.12,and the NedN end Safely
Cods,Nation 2553200+ Type of Roof
C]yr,Ye. ❑N.
Will rhe applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing, material being
mit hm ons air communities as defined by the Bay Area Air Quality Management installed. If a roof is Installed without first obtaining an inspection
Di`" `]
E]Yes El No I agree to remove all new materials for inspection. Applicant
ma
I have d the healumm,material."u..under Chapter 6.95 of d.e Cali- un erstands and will comply with all non point source regulations.
fmtde Health&Safely Cade.Savona 25505.25533 sal 25514.1 understand dust if the
Wilding does ua cmtend,have a tercet,Bea it is my responsibility to naify due occupxd
of the nenurcmenu which must W ma prior m i suvre of.Ce Tic.,of Occupancy.
Owner or euth.naed age., Dam Signature of Applicant-' Date
All roof coverings to be Class"B"or better
OFFICE