08100183 CITY OF CUPERTINO T�a,y* Kvt;::tag..��ri x f',r 3 a� •> 14'*n ` i a :
BUILDING DIVISION PERMIT ✓d.,�O,1�ITRAGTQRANF,�RMA.TION-5i,
nUILDING ADDR PERM"NO.
R'S NAME: PERM"SSUE DATE
PNO CONTROL NO.
ARCHI=AINGINEER: BUILDING PERM"INFO
'- BLDG ELECT PLUMB MECH
0 0 0
u00 LICENSED rksmam unORSDisions ATION
fchap
1-49
u 9 1 hereby af0m Nat 1 am 0¢e Bu under and
ftmu of Chapin 9(ammmcnring lob Description
nZ6 with Scetian]0cffan,Oivisian Sof dta BusiteasaM Profession Code,and mylicenseu
<�= n�enlseCleaneerca _ uv• 2 MFR&INSTL 1 DBL FACE MNUMNT SIGN; NON-ILLUM
n;: Dam Contsx]or
RCHITECrS DECLAR 1
I understand my plans shall W used as public
a
g C Licensed Professional
c 3 OWNER-BUIIDE RDECLARATIONaca
COO 1 boreso .(Site that I l vusin from tW Caston Co License Law for the
p Oy' following moon.(Semon]0715,Business and improve.
desiov Code:MY em or county
COO
prior te9NN' .permit reCOAM After.pplicnt for
N:,h Perlin nee a silted aINCWR
—zi primmi6isswncoursu requires tose tie applicant for nchpermi's Likes,Law Chap=9 .
mm<
that(comstatement
mencing
cingwitpursuant7000)ofDiviovofthe the
nicPm(=1w(C me)or Sq.Ft.Floor Area Valuation
egg (cam a is exe exempt
Section IDn d the
Division r of Ne Alleged
Business and on.Any
Code)car
egg that he is uempl Nem(rom entl tW buss far IW Welted eumptiaa Any violation of
Section 1071.5 by any applicant far a permit vbjcma Ne applicant to a civil Penalty of APN Number Occupancy pryYP e
not more then five hundred dolWa(5500). P Y7
01.s.ownv of Ne proputy,ormY eroPloytta wire wage uHeir rote compewtiv, 32633110 . 01 -
wiRdotWwart.andthesaumurtiswtimm�doroffe fmssle(Sec.]One,Business
and Professions Cade TW Comacces License law don asst apply in an owner,or Required Inspections
pmpenywho Wildamimprowsllbace .and wbodoessuch workhimselforthrough his
owmetnPloyees,provided dutsuch improvements art net intended reoffered for We.It.
however.the building or improvemern Is sold within one year of completion,the owner-
W ildu MR have the Maden of proving Nal be did roc Wild or improve far purpose of
sac.).
0 1.a owner or the property,Am exclusively ccaurani.2 with licensed convectors m
construct the project(Sec.7061,Business am Profusion Code:)rhe Cuntnctues Li-
cense law does not Apply to an owner of property who Wilds or improves thamon,and
who contracts for such projects with a contra mr(s)rewound parwant in the Contractor's
Lkeve law.
lamacmptunder See .B&I'Crar NMteamn
C Dam
WORKERS COMPENSAT]ON DECLARATION
1 hereby affirm under penalty of perjury one of the fallowing declandmom
❑I have and will maintain a Certificate of Covent to self-ivum fm Worker's Compete
cation.as provided for by Section 7700 of the labor Cade.for dm Performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation lavnanee,As required by Section
7700 of the labor Code.for Ne pcdormance of the work for which NU Permit is issued
My Worker'Qom a uav Iwrame cartiu and Policy nymber ere:
Carty,
7A-7lm, Na:f DV IIO ZOG`�i tl
CERnFI IE OF EXEMPnON FROM WORKERS
r COMPENSADON INSURANCE
(rhisunion teed rot be completed if the Permit le farm hundW dollara(5100)
or less.)
I certify Nat in the performance of the work for which Nis Permit is issued 1 shill not
employ any person in any many an As to Wcomc subject to the Workers'Compensation
Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,After making Nis Cettifiam of Exemption.you should
become subon An Ne Workers Compensation provisions of the labor Cade.you most
.J O foMwiN comP1Y with such provision ar Nu permit dull bo domed revoked.
^ CONSMUCnON LENDING AGENCY
[—ice I hereby drmn the dmrt is a consuuctiun lending agency for lW performance of
fk> the work N
for which is Permit is issued(Sec.3097,Civ.C.)
aA Lender's Name
=) z lender's Address
U O 1 certify that 1 ban reed this application and sum Ihu the above information is
U, E coma 1 agree to comply with all city and county oNinances and sum laws miming to
.C) Wilding cansauction,and hereby Animal representatives of this city in enter upon the
W above-mendomm Propcmy for iupectian purpmes.
(We)Agme to save,indemnify and keep harmless the City of Cupertino agent
Uy liacmeacquercemco se,gm and expcnsesrnit. mayN any wayamue•{aivcsald Cicy
V z in cense Alum of the granting of Nu permit. n
^ APPLICANT UNDERSTANDS A WILL COMPLY Wfm All.NON-POINT Issued by: Date
SOURCE RECD /
Re-roofs
Si{ ort of P can o r Date ��---
HAZARDOUSMATERIALSDISCLOSURE Type of Roof
Iby the
Cupertino
no forum bpal Code.
Chaptnom m handle harudaus material
fined io the Cupertino Municipal Codc.Chapter 9.13.and site HcaIN and Safety
:. CY.2ss72(a>7 All roofs shall be inspected prior to any roofing material being installed.
❑res gNa
Will the app scam os.future Wilding aceoWnt use equipment or&,i.which
If a roof is installed without first obtaining an inspection,I agree to remove
emit havardnn air contaminants a dcfmM by the,Bay Asea Air Quality Management all new materials for inspection.
D strict)
❑Yesy
1 have mad the hvaadnvmaterials mquircmenu under Chapmr6.95 of Ne Califor-
niaHvlN&SofctyCode,SccdadsBMS.25577 And 25734.I unNnand thuifdm Wilding
doss not cumnlly have A¢nen Nat'yy u my rcapoviM1ility m notify the occupant of de
requirtmentawyw1r mel ern issuance oft Certificate of Ce'.pasey.
e � Signature of Applicant Date
owner or auN7seem
All roof coverings to be Class `or better
Date g assf�