00030055 CITY"OF CUPERTINO PERMaNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 000300 6—,5—
HUILDING ADDRGSS: Al �'
O O y9r r��,yr�p//�{/�'/✓�D�/•^4/aJ/4�µ�k�'I/J � SANITARY NO. APPLICATION SUBMITTAL DAi
O :PER'S NAME: / G 25-31 G7,k%'-a`✓/O//�/)uy/ Ale. N/C CONTROL#
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ARCHITECT/ENGINEER /,.r-r�l/J��/�o O IULDING FERMI I INFO
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j LICENSED CONTRACTOR'S DECLARATION
I bonds,affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
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F,o.t-J with$«uon'lOpOlaf Diviiion3ofde BusinusatZ
Cade,aM mYlian4e
z�d 4 in run force and t /deo%ire
tL O d O License Class - Lia#
3 a F Dam Cmtnctor
O g ARCHr1ECTS DECLl.odentandmyplanashillbe usndrapb
C oc
i d: licensed P rfeulrul
y OWNER-BUILDER DECLARATION
C Z a 1 hereby affirm that 1 un mnnpl from Use Contractor's Lienee Law for the
no following .(Session 7031.5.Bunn.arta Foulco ccs,Code:Any city or--'YntY
ruboro which nNums a porn isre Comma.atter,improve,demolish.or repair any svucturc S Ft. Floor Area V$$luation
3� prior to its issuance,also requires the applicant fM such pedm;t w file a sigmd ataWment q �yyQ �j 1r
that he is licensrd pumu
uanome provisions of the Convacwte Licame Law(cornier 9 Vr�! 40
(4ammencmgwith S«um7two)of Division 3afroc But.and Pnfea.mns code)m ppN Number Occupancy Type
that he Is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 70315 by any applicant for a parrot subjects the applicut t0 a Civil penalty Of
rot more Wen five hundred dollar(550M.
❑ I,,4nwmrnfd#prnpnty.nrmyemp�mawiWwagea.,mcirwiccompnbation. Required Inspections
will do We work,.yd thebwctuin is not intended orolfc ad torso].(S«.7044.Bualncu
and professions Cosic:The Contractor's License law dm trot apply to an owner of
propeny who Wilds Or impeovex theteon,ash who dna such work ldmsell on through
his own employaa pmvldW Nat such irepmvemenu see not intanded ou Oficrtd for
We.If,however,the Wilding or improvement is sold within one year of completion,she
wmrWild"will hose the burden of proving that he did rot Wild or improve for For-
pose of We.).
❑L as nwmr of the property,am exclusively conuecung wish licensed convaeton to
croswm the project(Set.7K4,Busineu and Pofeufou Code:)'Ihe Conobaeof.Li-
came law do"Mn apply ve an Own"Of property who Wilds On Improves thmmn,and
who contracts for such projects with acono-ecton(4)ficensed Pursuant to the COMWOCO's
License law.
1 am exempt under S«. .B&P C for thismason
^tutor Data
WORKER'SCOMPB.NSATION DECLARATION .� V
1 handy illfrm send"cendty of prrjory one of the following wodualai
keesCo I O
Ihave and will for by exon 37 inof do,Labor
fm the wmkefa Compen- 1
tion.as ptovidnd for by Section 3700 of the IaWr Code.for We performance of she I `f
mJs'fm which it,
parrot is i4wed.
m/1 haVe sed W III maintain Wnh"S Compensation InsufMCC.65 f�ulred by SIXtIOO /t
3 two!the laWr Code.lM thr perrgrmame OftW Work fm which this pemnil is iuued. L!'/`/
My Workers c mpenution lac Ismer andPolicydIhh he
c.rrier:�jLERTI ICf3n� Perry Nn: WORKER 3R/n
CERTIPIC OMPESATIONIEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectio rad out he<mnpleted if the permit is for cove hu,mN ddlan(5100)
Loy mythatin the petm,a mover
s tworkfor which thus to W is ibsuad,Lahil1
radne Lau, of personin uY tunmr m u to bcconne subj«I to the Wgrtm'Compen-
smion Lews of California.Dace
Applicant
NOTICE TOAPPLICANT.If.C rakingthio CcNfcam of Eaaborost You should
Femme subject to it WOrh to.Compensation provisions,usol of the Isom Code.You must
forthwith comply with each provisions or this permit shall W tamed invoked.
CONSTRUCTION LENDING AGENCY
Q Q1heoeby off.in.there is a construction]coding agency forte pMmme o,a
.Za the work for which Nis permit is issued(5«.3097,Cls.C.)
IendCe'Name
�[ 7 LendrevAddress
W 0 I certify shed 1 have read this uppheation and state shat the above infomation n
Ow Co.,.l agree,to comply with 01 city sed county Odi..r andbate law,relareg Ir
.• z building cootructionand herebyaoloon.reprnsursoves ofthil city to emerupen the
U aMvemerioned property for inspection purposes.
Lk. F•, (We)agree to save,indernrhry and kap homleu the City of Cupertino against
U uehiliu".judgreens.emu add expenses which may in any way accrue against mid City
>a W in consequence of the granting of this pe
[� 0- APPLICANTUNDERS' NONAN I I.I.COM PLY WI'I At.].NON-POINT
U Z SOURCE RI!(WIA'D N'.
y 5
Sigmmre of Applicani/CODate,
H US MATERIALS DISCLOSURE
Win the epplicemo tort Wilding Mcupm rove or handle hasudoua matenil Re-roofs
as dafined by the Cupertino Municipal Code,Chapter 9.12,'and the Health used Safety Type of Roof
Code,Sation 255324)? yP
❑Yea m1fe
Will the applicant or future Wading mmpent use equipmenwr devices which All roofs shall be inspected prior to any roofing material being
.mit haurdous aft conteoiunuadefinal by the Bay Ams Air Quality Mavagcmcnt installed. If a roof is Installed without first obtaining an inspection
°bth°t' I a ree to remove all new materials for inspection. Applicant
C],:,Yee
I ha a read the ha,,.&.,material.requuemena Custer Chapter b95 of the Cah- un erstands and tui omply with all non point source regulations.
forma Health&safety Cade.Sectors 25505.25533 and 25534.1 understand Out if the
Wildingd...currently laves luanL that it is any onWnsibility to ratify the occ.pam 2 /
of the rtyu'ucmuu hich mus mel priortoisaurce ofa CuifcarenfOcIez
Signature of A Ic• t Date
onsmor..Won en f Dale
All roof coverings to be Class"B"or better
OFFICE