00030158 CITY OF CUPERTINO .,•; -. PERMIT No,
BUILDING DIVISION PERMIT CONTRA(JT VJ&ORMA�17IO,N�'s," O O l�3 Q /,T
g
;ARCHITECT/
ILDINGi,4—S: Tl. CI e&& 1Z� _Tw(f SANITARYND. APPLICATION SUBMRTAL DATE
N[R'S ME: Li^ 3 s 33 Coasts //�f C 24. NIC CONTROL#
GINEER �.� C� %HOLDING PERMIT INFO.
w
LICI NSED COND ACTDR'S DECLARATION
ZO G C I heeby affirm Net I am licensed under provisions m
of Chapter 9 tcomenaing Job Description
F�^tot with Secdan)0)0).G)wiaim S afthe Bainessand Profasime Cade.and my limue it
4 O U UfuR farce send effect _ 5 - 4. /J
L Data ch. Contractor-
0
CMCJ J LI'vL/�—
g LL y
Data C S DEC
t a O g ARCHITECTS DECLARATION
f pr, lundenmd DIY Plans MJlhas used Uparse roads ,
a�z 1Jcansed Profaaioeal
OWNER-BUILDER DECLARATION
t is a 1 hereby affirm that 1 am exempt tram the Contramoas License Isw for the
FF 0 following mous(Section)0J I.5,Buaimes end Rofeuiam Code:Any city a roam,
which rtquisa v pemdt to construct,alter,improve,&.[id,ar rtpa'u any s�ucture
a_ Sq. Ft.Floor Area Valuation
primmite.ao rtge appEc
anfor ouchpemdt mliltasged t
that censed Frontier o the raiiom of Ne CowutoaeoeawlClopho9
(ccreco em,wiCSa0mofDvimlofNeeuiw andFavi Cadc)or
Nrhe is exempt nrtfme and de bassfor the rion Any t lof
pL mbev_
Occupancy Type
Section tl by any for a permit mbject3 she plicat to a civil penalty of
no'mom Nen five hundred 11500).
❑Laowurofra,promnYormyomployen
orOwagaurhe(Sce.comps O Required Inspections
and do Newark,Codd: see Core ismxintended ia. e,dosfar arapply.toan,Buuneaa -
and oney when Code:The Conwcmh Lienee law dos bar apply m lf ownergh
prapmY who Wilda or Improver a Nem e,and who dao such week himself a through '
hasW own employees,provided Cat each improrcmrnwithin
art not intended or offered for
We.If,hlder wiCc veshe bng ar improvementisf soldho did h au yucaimprove for ar. 3
ower-s de.).will have Nc WNen of proving Nat he did not Wild m improve for par-
posse
❑1,u owner of the Smpeny,am niece,and cgnusedng with Ii The Cemheanmn U. /
m masse
La dm does
apply
to nd, .of end PY wines m Cadet mCmbacm8 V- �y
cense IoW docs ret app1Y m an owns of peopcnY wines Wilda m improve Centro.sual
m's t/ O
whomvu
ntsfofor pojmu with acmvaaodd licensed puan
nusta the Conuacmas t -
License U. '
❑tem exempt uimerSec. ,BdPCfor Cis rtum O
owner Des h - ••
WORKER'S COMPENSATION DECLARATION O
I hereby affirm under penalty of perjury ou of the following duluaiou: -
IWvprovidllfaibivetion37MofC Utter ode,furtfarerformaCompere -
woion, rprovided!or by Section 1'!00 of Ne Leben Code,lm Obe performance of the
work have
whichiler
la pmitis iuued.
t]1 haw W will ode,fin Wrrkear.Cr m,afthion kfma,hi u rtquval by Section
My Wmles Co Cmb,fon Iepertormannot andcwost fmwbir h Nisamtit is issued.
My.,Carrier:
s Compensation lnmhantt cartia and Polity number oR:
mer. Policy
CERTIFlCATEOFEKEMPIONMOM WORKERS" '
COMPENSATION INSURANCE '
labs agiennend
mootfacompleedifNe pertnis is forenehuMdolla x(5100) -
Or Ica.)
I cedif hat in thepertwnteswe fhe hich Nie permit is issued,Isbell
nattmpley y Tammany ner as to subject to the Wotan'Compo- -
setionLa eco vlifomia. -
Appi
OTIC PL A ni N Corti&aa of Labor rad Youehmld
s lac Workcae Com moron proviaiom of she Labor Cade,your mus •
f i comply with such Provisims ar Nis peemit shat W d«med mooed. FY w CONSTRUCTION LENDING AGENCY 11
� Q Thereby affirm Ow Nem tee construction leading agency for the performance of
Z the work for which Nis#omit¢iasuN(Sm.1097.Civ.C.)
Fy Lendeae Name D
W ; ad aIAddmaa MAR 2 4
W Z ICgres,o Ihave Rad Maty and counaneaWe that the saw l ImfmrNYar is - 2000
F4 Co.,.l agree m comply with all city and marry mtlinencOf this awe lawn r upon the Z building adramd proeM horcimeacerim perem. wive of this city menta upon Ce
V Q above-(we)a ed popery for thspectian keep ba.
f; Fw cs,juagesmsew,indemnityand kap hay leirsin
da City ora.l.. 1ageit ty
Q V liabiliva,jndgmrnu,caste and expenses which may in any some ageiuwid City O �_��`•� '
} W ineonesequ
ueeofdsegondngof0dspemdt.
(•+ 0, ADPL NTUNDERSr NDSAND '1. COMP ALI.NON-POINT
11 5I C REOULATI
" K �y5.So
of onvact One . • .
AZARDOUS IA DISCLOSURE ,
Will the epplicam or lumrt Wading omupant state or handle harmdau notarial Re-roofs '
defined by she Cupertino Municipal Code,Chapter 9:12,and the Health and Safety
Cade.Seca.25s12W? Type of Roof
❑Yea ON.
Will the applicant or factor Wilding occupant use muipmem or devices which All roofs shall be inspected prior to any roofing material being
vth.aNaaa a'v eanCmiunts.r deBnal by Ne B.y Am.A'n QaNity Man gement" installed. If a roof is Installe ithout first obtaining an inspection
"" I a nee to remove all new trials for inspection. Applicant
❑Yes ❑No
Iharc rted Ce haruduh.m.edda rynirt order Groper 6.95 of the,Gari. un stands nd w' co with all non point source regulations.
f Health B Safety code.Secdou 25 ,25s d]35M.1 undeaund Nat if rhe -is ,
If does nm Yhercaa sets:, ma ihiinymmtifythem.prom r-7
the u'vemm h' M1 eau mm' of a Certifitae of Occupancy.
a of pplicant Date
e d agent I Data
1 All roof coverings to be Class"B"or better
OFFICE
CITY OF CUPERTINO .,•; -. PERMIT No,
BUILDING DIVISION PERMIT CONTRA(JT VJ&ORMA�17IO,N�'s," O O l�3 Q /,T
g
;ARCHITECT/
ILDINGi,4—S: Tl. CI e&& 1Z� _Tw(f SANITARYND. APPLICATION SUBMRTAL DATE
N[R'S ME: Li^ 3 s 33 Coasts //�f C 24. NIC CONTROL#
GINEER �.� C� %HOLDING PERMIT INFO.
w
LICI NSED COND ACTDR'S DECLARATION
ZO G C I heeby affirm Net I am licensed under provisions m
of Chapter 9 tcomenaing Job Description
F�^tot with Secdan)0)0).G)wiaim S afthe Bainessand Profasime Cade.and my limue it
4 O U UfuR farce send effect _ 5 - 4. /J
L Data ch. Contractor-
0
CMCJ J LI'vL/�—
g LL y
Data C S DEC
t a O g ARCHITECTS DECLARATION
f pr, lundenmd DIY Plans MJlhas used Uparse roads ,
a�z 1Jcansed Profaaioeal
OWNER-BUILDER DECLARATION
t is a 1 hereby affirm that 1 am exempt tram the Contramoas License Isw for the
FF 0 following mous(Section)0J I.5,Buaimes end Rofeuiam Code:Any city a roam,
which rtquisa v pemdt to construct,alter,improve,&.[id,ar rtpa'u any s�ucture
a_ Sq. Ft.Floor Area Valuation
primmite.ao rtge appEc
anfor ouchpemdt mliltasged t
that censed Frontier o the raiiom of Ne CowutoaeoeawlClopho9
(ccreco em,wiCSa0mofDvimlofNeeuiw andFavi Cadc)or
Nrhe is exempt nrtfme and de bassfor the rion Any t lof
pL mbev_
Occupancy Type
Section tl by any for a permit mbject3 she plicat to a civil penalty of
no'mom Nen five hundred 11500).
❑Laowurofra,promnYormyomployen
orOwagaurhe(Sce.comps O Required Inspections
and do Newark,Codd: see Core ismxintended ia. e,dosfar arapply.toan,Buuneaa -
and oney when Code:The Conwcmh Lienee law dos bar apply m lf ownergh
prapmY who Wilda or Improver a Nem e,and who dao such week himself a through '
hasW own employees,provided Cat each improrcmrnwithin
art not intended or offered for
We.If,hlder wiCc veshe bng ar improvementisf soldho did h au yucaimprove for ar. 3
ower-s de.).will have Nc WNen of proving Nat he did not Wild m improve for par-
posse
❑1,u owner of the Smpeny,am niece,and cgnusedng with Ii The Cemheanmn U. /
m masse
La dm does
apply
to nd, .of end PY wines m Cadet mCmbacm8 V- �y
cense IoW docs ret app1Y m an owns of peopcnY wines Wilda m improve Centro.sual
m's t/ O
whomvu
ntsfofor pojmu with acmvaaodd licensed puan
nusta the Conuacmas t -
License U. '
❑tem exempt uimerSec. ,BdPCfor Cis rtum O
owner Des h - ••
WORKER'S COMPENSATION DECLARATION O
I hereby affirm under penalty of perjury ou of the following duluaiou: -
IWvprovidllfaibivetion37MofC Utter ode,furtfarerformaCompere -
woion, rprovided!or by Section 1'!00 of Ne Leben Code,lm Obe performance of the
work have
whichiler
la pmitis iuued.
t]1 haw W will ode,fin Wrrkear.Cr m,afthion kfma,hi u rtquval by Section
My Wmles Co Cmb,fon Iepertormannot andcwost fmwbir h Nisamtit is issued.
My.,Carrier:
s Compensation lnmhantt cartia and Polity number oR:
mer. Policy
CERTIFlCATEOFEKEMPIONMOM WORKERS" '
COMPENSATION INSURANCE '
labs agiennend
mootfacompleedifNe pertnis is forenehuMdolla x(5100) -
Or Ica.)
I cedif hat in thepertwnteswe fhe hich Nie permit is issued,Isbell
nattmpley y Tammany ner as to subject to the Wotan'Compo- -
setionLa eco vlifomia. -
Appi
OTIC PL A ni N Corti&aa of Labor rad Youehmld
s lac Workcae Com moron proviaiom of she Labor Cade,your mus •
f i comply with such Provisims ar Nis peemit shat W d«med mooed. FY w CONSTRUCTION LENDING AGENCY 11
� Q Thereby affirm Ow Nem tee construction leading agency for the performance of
Z the work for which Nis#omit¢iasuN(Sm.1097.Civ.C.)
Fy Lendeae Name D
W ; ad aIAddmaa MAR 2 4
W Z ICgres,o Ihave Rad Maty and counaneaWe that the saw l ImfmrNYar is - 2000
F4 Co.,.l agree m comply with all city and marry mtlinencOf this awe lawn r upon the Z building adramd proeM horcimeacerim perem. wive of this city menta upon Ce
V Q above-(we)a ed popery for thspectian keep ba.
f; Fw cs,juagesmsew,indemnityand kap hay leirsin
da City ora.l.. 1ageit ty
Q V liabiliva,jndgmrnu,caste and expenses which may in any some ageiuwid City O �_��`•� '
} W ineonesequ
ueeofdsegondngof0dspemdt.
(•+ 0, ADPL NTUNDERSr NDSAND '1. COMP ALI.NON-POINT
11 5I C REOULATI
" K �y5.So
of onvact One . • .
AZARDOUS IA DISCLOSURE ,
Will the epplicam or lumrt Wading omupant state or handle harmdau notarial Re-roofs '
defined by she Cupertino Municipal Code,Chapter 9:12,and the Health and Safety
Cade.Seca.25s12W? Type of Roof
❑Yea ON.
Will the applicant or factor Wilding occupant use muipmem or devices which All roofs shall be inspected prior to any roofing material being
vth.aNaaa a'v eanCmiunts.r deBnal by Ne B.y Am.A'n QaNity Man gement" installed. If a roof is Installe ithout first obtaining an inspection
"" I a nee to remove all new trials for inspection. Applicant
❑Yes ❑No
Iharc rted Ce haruduh.m.edda rynirt order Groper 6.95 of the,Gari. un stands nd w' co with all non point source regulations.
f Health B Safety code.Secdou 25 ,25s d]35M.1 undeaund Nat if rhe -is ,
If does nm Yhercaa sets:, ma ihiinymmtifythem.prom r-7
the u'vemm h' M1 eau mm' of a Certifitae of Occupancy.
a of pplicant Date
e d agent I Data
1 All roof coverings to be Class"B"or better
OFFICE