00050009 CITY OF CUPERTINO -' - PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INF_ ,ORMATION: � o o oq
BUILDING ADDRESS:
C7/ E. ����,//jyy'gyr SANETARY NO. APPLICATION SUBMITTAL DATE
I X Z v.
OWNtJt'S NI.ME: / J -7 ! / "
'y - ,_/ J� 4D NIC CONTROLp
CHI ECT/IiNGINEIiR �s �^ ('�` FO
BALDING PERMIT INFO }
1�u
LICENSEDCONTRACTOR'S DECLARATION
1 hcrcby,Rrm Nm T am liceved under pmvisiom of Chapter 9(wmmencing Job Deseription
Section]OOJ)oOaAskn3efma Busirournd Profimro Code.and my time.i.
oil force and effn. s Lie
.N
W 5 LL y D,u arlic cC
F-LL O g RCNR£LTS DECL A ION
v�y I undenYld my pWu EMIT W used Y public ravrd. G-- r
Cy¢
i a c Clewed Professional
OWNER-BUILDER DECLARATION
I hereby a(Sect 1 em exempt from ma Contractor's License caw for the
`S C following rcm
an,(Sectionon 7031.3,Business and Professions Cede:Any city m county
aC which mquirY a permit to construct,elect,impmva,demolish,m repair any mumme
's_ Sq. FL Floor Area �ation
PAW to its issuance.iliont:1.imprints the appB<aof(«Soon perrvno file a signed
met
naislicemeit pectins w Ju provisionsof Inc eBusinsss LicenseLaw(CMps9
f .he isi.m'IlSection]000)ofDivision3ofJacegedexevMmi.AnyomCodc)of �pNf�7w er Occupancy Type
IMI he is e.mpt tsefmm asm the basic for to alleged exemption..ci l per on of ? / Pl is p Y Yp
Section703 e than by any apphcma for.pesmis mbjec¢the applioYluo a cull penilry of J /V Y a
pt mom than five hundrtd t dollars y employing
Las owner of the propenY•mmY employsa Wim wages utheir sola comperowou, Required Inspections
wall do leendc:eche Cm 161w1lmnlded mow do far YlE ISK.]Ufa.w.of
and arty whoIs Codc:The over arm iand w law does nd applr to R Owns N
popery who Wild.or improvessuch
ancient.and who dos w. rote nied W o Juauew
his own employees.a Wovided io such impmveoldw tie nm intended m oRr..Int
Yle.If.however,the Wilding orimprovement iEsoldwithinoneild.1 cotnylnlor Ju
ownor-Wilds will here the burden or proving that he did rare Wild or impove for Par-
pow.f.1"
se ow .
I,Y r of ted
mpey,enexclusively<mlescdng with licensed contractors to
l t me (Sec.]Baa, Yd Poro Cods:)The Co
mewMw door War apply Y Yow.. propert,wine W lds oimprove minion.Ynd
wed<onLafor such pojecu with acmtrKmrfs)licc.d pursuant w der,Conusclofs
law,
C]IsmexmptolderSec.
.B&P C for Nis reason
Owner Dat
WORKER'S COMPENSATION DECLARATEON
1:7
affirm un4r peniley Of perjury oar of me following dK Watioro:
1sev Mlwill=un na CenifieswofConantmul6inmmforWmke$Compen-
7not
ion,as provided fm by Section 3700 of the tabor Code,for the plxfomusrs of me
.Wk "'which this permit is issued.
'fhevaand will maintain Worker'.Compensation Imuout Y e putted by Section
00of ma Labor Code,forme performarm ofJou wars for which this permit iE issued.
re°' wr A am�rrr� io ol/
CERTIFICATEATE 0, EPTIONFROMWORKERS'
COMPENSATION INSURANCE
fort.section need nm becompleedifJu pemdt u fWwwless.)
I cenifY .perfolmceoewkfor which this pemdl isi.und,irhill
employ any n any manner Y b[Co ep1�j coo to WOrkars'Cmnpem
Ytion laws of life is Dace F V .
Applicant
NOTICE TO A ICANT:I.dl ting this Certificate of Ewarp lea,you should
aso mme subject t Jou Workarc Compenviian provisioro of tete LeWr cone,you must
forthwith comply wit such mr isuria or this .it mall be domed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Jou mem is a coromcuon lending agency for the performance of
y me work for which this permit is Isaued(Sce,3097,Ci,C.)
F LEndels Name
�i > Larches Acidleas
Lv11 most,dust miwio
t 1 have d this eMlin and soIMto
sou due aWve infmmeuon is
Q. zcomm.I specie comply with all city and county ordinances and Euta laws retiring to
Z building conewctiOm,and hereby studied.repe.merives of this city to enter open JR
U C above-mentioned property for inspection purposes.
fes. f'I (We) we m nave,indemnify and keep humless the City of Cupertino against
f,
liabilities.judgments,costs and expenses which may in any way accrue against said City
in con. c of an
m,grting of Rpt it.
j-� C. AP", .ANI UNDERSTAN AN 11.1.COMPLY Wil It ALI.NON-POINT
V CA SOU CER f JUTATION. y
�0 s �z- �� 3. g�
amrt aI AMficardfCorturrectm I Ote
HAZARDOUS MATERIALS DISCLOSURE.
Willme epplimm orfuwrt Wilding KcupYtemm or handle hazardtus me¢tid Re-roofs
as daGmd by(be Cupertino Municipal Code.Chapter 9.12,sad me Neddi end Safety Type of Roof
Code,Section 233320)' yp
❑Yes �No
Wilme applicant ter Potter building occupant use equiprrcne or dcvims which All roofs shall be inspected prior to an
roofing material being
eWar
thardoua air meminemanas defined by the Be,Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
�/ I a tee to remove all new materials for inspection. Applicant
(]Yes �✓J�N\a
1 melvvudouamaterial. mcnbtoderClupar6.93dJeGili. un re and will comply with all non point source regulations.
fmrda t a
"YC
Code.Seetiou 3lJ red 253N.I undsslYd thaI if ted
Wilding ma termly Mix a is t, it is my scsponsibibry m notify me own ant
Ofd-M YVC le-iuc mYRI rlIN to lE6terle[OfeG fCC r.
Z D Signature of Applicant Date
(J aullwrized agar ate
All roof coverings to be Class`B"or better
OFFICE