00040071 T T
CITY OF CUPERTINO • • PERMITNO.
BUILDING DMS.10N PERMIT CONTRACTOR INFORMATION: I sat O ci/ry®„7 I
BUILDIINNGryADDRF.SS: I ' I ()� Mt�c 0B(V .,,. L9 41� ]yhl SSANITARYNO.T APPLICATION SUBMITTAL DATE
/fro /�L��' l Or{ofn fl l( JO�V-CK-I.�p 'JV :J. DpiAJ.a/� I Ll�2'•OO
OWNER'S NAME 1 CIAf..G�I'C OCL"/ N/C CONTROLO
' &A _ AWE.
ARCHIrEcr/ENNEER � BILDINO PEtMII'INPO
LICENSED CONTRACTOR'S DECLARATION
Z'O v' 1 hereby affirm that I sm licensed under provisions of chapter 9(mmmewi^8
F � .. Job Description
y-
oo
_k m with Section 7000)oflovin 3of she Business and Professions Code,and my license is _ s
a m full force and'Rats
g,c a License Class r, -n4 Lm N 41, 41Qa'G
w3 Dam 4r(/ 611% Contractors lL c $
k'SO ARCHITECTS DECLARATION
_J 1 understood my plans shall Be used in public rsnds
m i G RO Lo,cal ProfastumW ei _
c suS= OWNER-BUILDER DECLARATION
k Z G 1 hereby,aRrm than L ern exempt from The Contractofs Lams.law for the '
O following reason (Sation 7031.5,Business and Pmfessmow Cud..Any city.,.my + '
3$ wMen reclaims a arm�t b construct.Who.improve.demolish,or tryst'any nmmon, S Ft. Floor Area rgL' ^y Valup/[�non
Four to nssmance,alm ro,uims the applicant for such aim m file a signed statement q I OV I�O
thal h.is licensed pm u set W the provm.na.f the Conoamura lacenn Law(CWpttt 9 V
I<ummenang with Section 70007 of Drvinion J o(the Businne atl ProfnsunsCWel or ` J
That he is ercmpt therefrom W the Ws,for the alleged extmaon.Any vnomtim of / p APN Number Occupancy Type
Seemn 7031.5 by any applicant fare pent animals the applicmno a civil pa ugly Of
nut mart Nan five hundred dollars(55001.
p I;et owns of the proany,err mY employer.with wag..n them Wit compenssvan, Required Inspections ••
will do the work.and thealructum is not umndW moRnmd for We(S.7004,Buvnet, _
and Pofes ic"Cod.:The Comeacloi s License Law tl«s not apply to an Owner of
pmpeny who builds or improve hereon,and who,lm such work himself Or through
' her own amployes,pmvnded that such impmvemenis au not intended or offered for
ule'LLhowever,she buildan8mtmpmvement is soltl wthinoa Yw o(compleri.n,the "' a a A '_
,ruse.budder will lime the bmden.f pmvmg that he tlad not build onmprove(mar- _• ,
1,a owns of Be,property,an'exclusively convecting wish licensed Comrscmn in ,.
consul the project(Sec.7044,Bunneu and proBa ice.code:)Than conoamra L,
tense law secs ism apply tO an owns of property who Wild,
purnmpW thethereon ne.
who enseLmm(Onuch projas with awntramds)LcenaW punuw b the Conuacbrs
License law •. '
O lamaempt under Sec ,B A P C for this meson • // "
Owwr
WORKER'S COMPENSATION DECLARATION'"
1 hereby'Mimi under penaltY_of arlury one of the followin6 decleratiow
�°' I have end will mamnius Carole Once On. selMuslim for Workers Compact-
non
van,a provided(Or by Secs.n 3700 of the Labor Cade,for the artomsna of the
ark fm s,",thus permit in s ed. n ,
Q]1 have and will m.inuin W.rkcrs Compenation Insureae,u mgwmd by Saction
3700ofshe labor Code,for don perlOnnanaofthe work for which this permmnswW.
"My W. Co !n!;nlnanrance tamer and Policy o tprt--,l°I� p
Cenier �'}g•� P.L,NO:• C7Y DA ° v
CERTIFICATE OF EXEMPTION FROM WORKERS'Q0 g 7qq Y
COMPENSATION INSURANCE CbO, f�, -
IThs section need not becompli eddthe pcmuus for one M1iANred dol(an(5100)
Or nasal
I certify that in the artormmceofthe work forwhah thuspent is broad,I shall
rot employ any arson in any manwr m a b bcconr submit b thc Womken'Conan- - '
Aron Laws of CeLfamie Dat•
NOTICE TO APPLICANT If,after main,This Certificate of Extmpuon,you should -
_, became anblecl to she Workers Compensnian provisions of the labor Code.you must � ,
foMwith comply with such povisons or Ihs admit shell be damW mvokW. ' =I
O 0 •,1hemby affims that dorm n a canewcuom leolmg gencyfmdncpeT.vccd
it the work for which this perms s,sued(Sec.3097,Cw,C.)
F.. Iandees Name
=S Address
W 1 cemfy thn i have read this application and lose that the above Ofonwdon is
.7 Z cos t.l agora to comply with ell,c y end count;ordinances and sore laws mTom,to
'U Obuddmgeonatmeuooend hereby aultonurposesnwivn of llusciybenmr upon Thor
above=menuanedpmanY for Inspection purposes
Li [.° (Wel'agaes.sues indemnify and hap harmless thcymmC.,unrl against "
O (� liebihlos,3udgments g=4nd fffiis vwhich.,in tiny way vccriie a,einxneid City
SOURCE REGUI TISTANDSANU Wit LCOMPLY N'ITII ALL:NON=POINT
V � SOURCE REGULATIONS. ,
Sigrwurc ul Apphcant(Contnmm Dam .
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building Occupant store or handle hamrdous in emdal Re-roofs
a deEwd by the Cupertino Municipal Code.Chapter 912,end sht Health and Safety
Code,Section 853260?, Type of Roof
❑Yes �fto
• Will the applicamor future building Occupant use egmpmemordcviceswhch All roofs shall be inspected prior to any roofing, material being
wt hatuard"s air conuunmants as defined by the Bey Area AS OuWry Management installed. If a roof is Installed without first obtaining an inspection v
"pe7 kIAn I a ree to remove all new materials for inspection..Applicant
❑Yes g
IhevcrudWeharuduiiemalmalsuyuimmrnsunderChapier695O(thcDalr Understands and.will comply with'all non point source regulations.
human Heald B Safety Cade.Sections 25M5,8533 and 25534 I understand Ihea d That .. '
budding dos net currently have a swr6 don It IS MY USawibshry to toady the Occupant
„ of the rryuircmen,which must h sun perm m neueac or a Ccmfic a Of Oc¢uancy ' '
_M'4 LA �1j//Jao Signature of Applicant Date
(hone,or othoneW ant Dent
All roof coverings to be Class"B"pr better- °
OFFICE,