00100037 CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRf35: I'IiRS1IT NO.
2Af;�7 LC -rUO46 z Cc' s-11a')��loll 4 f O Oo`3`7
OWM1'I!R'S NAME: AI'I'LICAI'ION SIIIf UAI3i •
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)Nye, SANITARY NO. CONIROI,NO.
0-7.. ARCIII'I'IiCI IHNOINFER: HOLDING PERMIT INFO
W^O❑O❑ If1.DG ELECT I'U1Mit, MICH
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FN lib`IPN51!DCUNTRACI( si,i DECLARATION Job Description
O II by datum tl I lu ...
I 1 r fmmo
chncro n acing
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alwith SccIioa7(X)G)ofDiviOoa3 offlu,Ruc dl t .-Inas Col and rev licence ll
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s q 1 cc CP:: GL_ Liw #
ole 10• GOTIFI C. t Cc'1.7CfZ,
w 3 a Ano,had1'be S DLCLARAI I�,
[understand my plana shall he used u.public records
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w O LiaenscJ I'ndcv,innxl
ca
OWNER,ever.D1!R n he RATION
d 7��`, 1 hereby affirm on 11. eampt Isom the Contrnanr's I Airy c law fur the '
< which re re:woa.(Section construct,
Businevsand vc,dcrun.Cade:Any cityrncounty
O which requires a pennil m rons,mn,alcor.improve,Jemnli,h,or repair anY.arvnurc
at
i s wp', I , '1:, y ' II pp1' Inn hp ,1111 asigned.ttment
That he is li,etoodf .eau tire n l ilhe c Oarna,r La,(chi,as-9 Sq. Ft. FloorArca Valuation
pornarroarwing with Seauon 9000)of I)ata on 3 of the Busi less and I mass nuc Cal
or that he is exempt therefrom and the basis for the alleged exemption.Any violmion
or section 70315 by any applicant bat a palmi,edjR,l,,h,applicant In u civil penalty
IIItrnnrcThan Ilse haMmildollars($500). 2'^ tlmba Occupancy Type
°1,asownerofthe pmpcay.orany. cmployecs with rages m their sole compensation. v
will do,he work,and the strvcmrc is not intended nr offered I'or sale(Sec. Also.
Hata neaa ante rmfe„Iona Cnde:'I m Cm,mnan,,Liam,Law date,not apply to an Required Inspections
r of property Who build,,or norm...manna.ami who does such wank hi mwlf
or Through his own employees.provided that such improvements am not intended or
offered for sale.I If how the building Or InpowCanciat is sold Isilhin oneyear of C`_
c,rplf p r-h II IIInvade 1 d 11 hg Thai re J'J th 'Id nr
.1. p m of )
construct
on ran PnrcnY I dycontractingiit Cod J t t tom /�
ut tan p j 1(Sec.71X,I li , J I is. s Coda:) a Contractor.
.,.meat lard docs con a inc n,u nw rr of p nontr what bullar' pursuant
t themor,
cora who conwens ran inch pmjatstwith n mnmednrhl licensed pur.uum to the
C) ns License Lw
a .
❑,nor e
1 um exempt under,sec. .B&Y C for This maxed
Owner One
WORKER'S COMPENSA'130N DECLARATION s '
737M1 hereby notion under penalty of perjury one of the following declarations:
have and will nmin rd.a Caribbean,of CIO,aat to salbir,um far Worker's
penstion, as provided for by Section 37M of the Labor Code. for the Temoorary Pe It
ormance of the work for which this permit is issued. Le
have and x111 inainmin Worker's Can,men,mion hawr.ner,as requircd by Seem. n
of the Labs Code,for th`iwrfort an`e of the work for which that p`nnh i, Issued prier to plan check completion
d.My W,kak ovation Insurance carrier and Policy number arc u�._.k�) .� nlicyNn.:lN.ca-r.�.� 004 zl'-olio Contractor and/or Owner accept complete
Yl” 'A'I'10N OI'EXEMPTION FROM WORKERS
COMPENSATION INSURANCE. responsibility for correcting additions,
frhis ,c;inn nue,tan,I he enmplcwd it The Tcnnll is for one handrail dollars omissions and revisions on
($1 00)of les.) - f
1 certify on
ail that in the rarrn ,unce,of the work for which this Ioil I.issued.I completed Blue Prints.
,hull nor c:npiny any„Donn in nay naval...as m heeonle subject to,hc Wmkeo' Perm good for 030)thirty days
Cmit"nani I Law,at C.lilornat Dat, -
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Emnnrtion,you should 6
1
Z bavme.snoca m the Workcfs Cnmpen,ation provisions ofthc tabor Code,you most From ` CJ
Q O Innhwi,n cnn,ly with...[pnrvlaion,or ata,Ise , shad be d,ennod revoked,
7
Vl CONSTRUCTION LENDING AGENCY
a > I hereby affirm that them is a conotmcdnn lending agency for the performance Signature
ul,he work for which Ihl,perms,Is isucd(Scc.3097.Civ.C.)
Q Lender's Nanrc
7 Z ladder's Address pates /O
V 1 certify that 1 have read this application and sane bat the nhnx infonnmion is
Orr [r c,ma.I ngne I cat I,,Iy with all e,Iy and tanally ordalanec,and stare law,mluling k
V Ire m
buildingcoaaction,and anarchy amhorveseprenmllyes al n,
misady in enr upon
W the aKne-nnemicand pm sa,for m,pection purpuus. '
FS III,save.indenmifyand keep hamlcso the City of Cupertino against
7V] Iialola u,,udgm.nla,'I""And a,arors which may In m
any way haee uguina Ilia
Z City in cnn r,peawc rel the Granting or Ihis pennil.
APPLICANT CUR NDS UWILL COMPLY WITH ALL NON-POINT Issued b r� Da '
SOU0.CE 1. S. p•S'•OO
sig:,, ,�llaanlra -r -� Dam Re-roofs
A%ARIy(IDS MA' Ls DISCLOSURI!
Will the apphcnat or alum buildingoccatpaot smm or handle ha..edous material Type of Roof
av defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Scctinn 255321:5!
°Y06 DNo All roofs shall be inspected prior to any roofing material being installed.
Will the applicant orfuture building neeapantuse egnipmma
eordeviceswhich If roof is installed without first obtaining an inspection, I agree to remove
ash Imenrdnus air com
mnin:uns a,defrwd by the day Amag
Aran Air Curdy Muncmcm
<Iriet3 all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
1 have rad Tic hcardonn malarial,requirements under Chapter 095 Of the
Cxlltinaln Ilwhh h Sul'c',lSccliuns 25515,25533 and 25534.l t n knead that
it the building dor,no,currently hate a mn.nl.Ihat i,iv lly rcm
gdsihilry u,....lily the
occupant rel the rtyuimments which mull he metprix m iscuamc of a Cenilicaa of
y' Signature of Applicant Date
ownarnr�mh —� Date All roof coverings to be Class "R" or better -
OFFICE