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00020077 CITY OF CUPERTINO PER IMN0. BUILDING DIVISION PERMIT 21 NIT"RAl"112R I, aORIMAyTiION,: 00O P,06 77 BUILDINOAIIDRESS yr � qK\// /� / SANITARY NO. APPLICATION SUBMITTAL DATE S NAME: (r 0 //V l'� © D� ^1 �- epQ� NIC CONTROL0 1R'I I/1 f/h^I M4 P. �lrC.�N Yl. El ARCH I'1'EC//E INFER ` n U?UIN(10;ERh1TCiINP�3 FO N LICENSED CONTRACTOR'S DECLARATION 0 „ - °Z l-° 1 hereby adidm Net 1 am licensed undo provisions;of Clutter 9(tammeming Job Description T.,=hw Swoon ueu )of,DC/iJ.v�ts on3of the Business nd'prolamines mmsessi ff so ce .. r/ I C O g ARCHITECTS DEC ON - 1 undentaM my plans shall W used u public mmr3s K <5 ii a c� Wcemm Pmfavr,W ' ,hat OWNER ason,d BUILDER m CLARAT to h4< 1 .. aRrm Inn 1 am exempt from Ne Comatoh License law wi the , I s❑ which re mason (Salon W31.5.construct,t,alrcss and ins,prolamines e Code Any city m county, 3 which requires a pem,n m comwcL afar,improve,d<mohN,or spur any amcturc Sq. Ft. Floor Area Valuation primto its iswance.also requires the applicant for such period uo file a aigmd swament that he is licensed porcuannndia pmvrvons ofthe Contractors Lianee Law(Cousin 9 '2- b Qb (commencing with Section 1000)of Mvision 3 oldie Exaimas and Profmarnscodgm APf�1 Number OccU anc Type Out he is exempt therefrom aM the basis for the alleged exempnon Any violnion of (J 3 (_/ f P Y Yp Salon 70315 by eny applicants fa a pemduub4au the applicator to anvil pemlty of 7 / 0 0 7 �O nor more Nan five homd,d dollars($500). , '0 Las owner of the property.or my cmplryees with wegeca Neinole compemauon, Required Inspections will do me work,and Ne SmC Lum is not intended cordoned hands(Sm.1044,Business and profit onto Code:The Contractor's Co...law does tut apply to an owner a property wW Wilds or improves Neon,man who alms such wools himulf«through Ms own employes,povided Nor such smpmvermms art now monodist or odue l f. We lf.however,the WdWmg a,mprovems,iuold whin one year/completion,the , owmmW Jder will have the burden of proving that he did not Wild m orpmve for puo- pose of ale.). ❑1.u owner of Ne Property,on exclusively contrsung with licensed conoatots to S N comtmn the puma,(See.1044,Business wd Pmfesios Code)The Contiectos'I V- or.Low alms rot apply m ea owner of property WW Wilds rrimproves,herero,ad who com.t.(mauch pmlao"ols noadrr(s)licensed pursuant m dhe Curiousness License law.I am eaemp,udder Sm. .B&P C for this reason OW.n-. malt j WORKER'S COMPENSATION Uf one following \/ Ihreby affirm under pvWyofperlury one of do follrwio{dcclaral,mu. , ❑I nave and wall for by won 377 ofCommto ods,fort for WmkcB ce of the Q , cation,s provided for by Swoon 3100 of Na LeWr Code,for the performance of the ,yell fur wh¢h Nia peml,n issued _ - ' eve and wall memwn Worker's Compenaetion Insuswce.a rcgmrW by Satinn 3100ofth LeWr Code,for Ne perfamunce o/the work for whmh thiv pem,t,s ia.um. , MyW (.0 ,on lnsurantt certis entl PolicypuWlyf grS'�y S;�nIY ' CATE OP EKEMI?ImN FROM WORKERS' COMPENSATION INSURANCE (ThuxecnnnnaA notWmmpletedif Neprnninuforonehuralmtl dollars(5100) t colors.) I ccnifythm,n Ne tedomam'eofNe wok(orwhteh this pcmutitnued,l rhall ' Aconn..Laws any peiwn ia ay manner m as m Wcrnu wbjcn w the WaAen'Cotnpen - LaWa o(Calsfomia.Dv- n, NOTICE TO rt to me Worker 1L Cie making thin Cisman,of of Eaammim,you should hecome whoa,y the rusher's Cnons or pmvi"of do Lebo Code,you man ' feMwM comply with such provisions m Nn peon shall W decrned revoked. CONSTRUCTION LENDING AGENCY 0 I hereby aRnn that more is.cennmetom lending agency Rothe pwfi.e of Z the work for which Nn peon n usuad(Sec.3091,Cm C.) Lenders Nem- Lenders Address Y \ 1 J {w W 1 certfy that 1 have mad this application had sure duet this above nomination is 0. correct.I agree to comply with all cry and county ooduuntts andwas laws mlidn'do lJ R �f U .7 Z building commuctim.enit herebyamhunu reprosomovesoftMs ntytoenterupontin MAR O 2000 V O above-memioncd pmpeny for inspection putpoas , La, F (We)agree,r suet indemnify and keep hamless the City of Cupertino against - C.) liebihus,ju meats,casts and estimates which may,.any sayincmeagaler,said City �r W ,nconsequ, aofthegrantingofthupeorm. F a p PLIC , UNDF CT S 'D WII COMP Yx•ITHCALLN^ON-_POINNTTJ_I E3V VZ Si avert cal ApFh , r _ Dole eHAZA ERIALS DISCLOSURE will e cam ni ni W Cg meopu t corerhanl e WSNOUS motenal Re-roofs d i by the Cu pero Municipal Code.Quitter 9.2,and the Health aril Safety ema.Sw ic m sss3x)1 - Type of Roof ' ❑Y.. Nr Will the applicant or future Wilding occupant use equipment ordcvices which All roofs,shall be inspected prior to any roofing material being emit harardma an contaminwts as defined by the Bay Area An Quality Management installed. If a roof is Installed without first obtaining an inspection °' I a ree to remove all new materials for inspection. Applicant O Yee. *a g I wva mad the haraadm,mmenal,requiements order Chapter 695 of the Cah� understands and will comply with all non point source regulations. fomu HeaUh&Safety Coda Sections 25505,25533 said 25534.1 understand that if the ' - bmMingdoesnorcurrcmlyhaveamont.that it is my m.ponaddity to notify me occupant • of the regmremenu which man W met pnor W issuance of a Cm,ficam aQcupwcy. Signature of Applicant Date OwmrorwdronzW agent Data - All roof coverings to be Class"B"'or better OFFICE' '