00040099 CITY OF CUPERTINO - PERMITNO
BuD.DING DIVISION' PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: 21 Ai� // 5, I •`ON SANITARY NO. `• APPLICATION SU MDTAL DATE
aoft A r, 17L`C^R Ley)
OWNPRN S:AME: I V.J D .�rjd�E 1 I C ^
<rg .'1w �y N/C CONTROLp
PHONL: , ,c S �A• C IQYT It
C'a4 ❑
RCHITELT/ENGINEER BULGING PERMIT INF°O
0� Ae)A 409- L44 -71o6
`ISoso
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LICENSED CONTRACroRS DECLARATION
a y z I Wmby affirm Nat I rum licensed under providtem of Chapter 9(commencing - Job Description A`�
FvUEa9 wile Satioo 70IXB of Division3ofdu Busincn and Profesdom Cade,aM my li<enu is ,, ",
�YC j in full forte ad eRcd. `•
license Clan Lic.N
u�3
Data
0 y 4=r'�Q'a• Con DEC �n .
I_a�O g - ' ARCHITECTS DECW TION •G ,�'k( �py�,Q,r PO l.e' _
u•N I undersand my plana aAill W aced u public recorder t - 1 - � ,
�¢f
Ucrosed Nofessimad
a u OWNER-BUl DECLARATION
t- I hereby diirm that 1 am exempt from the Contractors Licence Isw for the
E O following scatter.(Section 703 1.5.Bminmss rofe
and Pasiok: the CorMy city county -
which requires a permit m comwcl,alt.improve,demolish,re nepal,any sme.
H
parcent nwnce.JiarequimstheapPlinmfmauchpermdtmfileasignWmtencent Sq. Ft. Floor Area Valuation '
Net hal ix licenced pursuant Ice the providwa ofdR Commicrers License l-aw(Chapter 9 '
(commencing with section 7000)ofoivltion 3 ofthe Bad.and Pmreasions Code)on, APN NDmber � Occupancy Type
Nat he is exempt therefrom and the basis for the alleged exemption.Any violardw of _ _ —O p }r yp
Section 7031.5 by my app0cant far a permit subjects the applicanu...ivil penalty of -' "
.mom tom Ove Wodmddoll.($500). -
am
'1,as owncr of Ne propcny,ter ter employee.with wagesutheir tale compenseuon, Required Inspections
will da Nc work,eM tha structure is not intended or offered for We(Sm.7010,Bastion - -
and Profeuiom Code:The Conuacmr:License law don not apply to an.1 a
prolan who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impmvemenu art,not intended or offered for
suit.If,hoaevcc the turning m impmvoment it sold aorlim ate yese fmmilmirs,he _
own<nWildm will luvc ted burden of proving that W did nor Wild or improve for pun
- pose.fule.). . . .
❑I,as owner of the property,am exclusively contramng with licensed mnGmmrs to _ -
construct the po mi(Sm.7(110.Badness and Profeaions code:)The Convector's U- -
me Law does nm apply to an owner of property who Wilds of immoves Neuron,and .
who meds far such projects cte
with a nwdos(s)licensed nred puuntie,Concrte !'
Lice Lew. `
❑l tem exempt under Sm. .B&P C for this recon -
Owner '• Date • , �/�
WORKER'S COMPENSATION DECLARATION /
a�� i hereby affiw under penalty of perjury ore of the following declarations:
eY Im,emid will mainteln is Ctiificis.of Cement o self-insure far Weekeis Counties.
ureter,as provided for by Section 3700 of the Labor Code,for the performance of the
v k for which this pewit is issued.
I lave and will maintain WOM1eh Compensation Imuv
ra<.as required DY Section - -
3 of the[Ahm Code,for the'do.,M he work for which this pc.is is issued.
My Work is Cotrym rani:, .uryna`yny.ley No.Y f
c.rdmP3`�C A L�Ic _^,�^
CERTIflC OMPEIN AMON INN FROM WORKERS' n
' COMPENSATION INSURANCE ,
(This secnian need not WcomPletedif dre Pewir is forooe huMred doll.($100) '
or lesx.l '
I certify Nan in the performance ofthe week for which this permit is issued,INill '
nm employ any person in any menneryo a'tp lsc"mgeim,to the Wurken'Contain
.tion Isws o .Dam GF' 1'l (JV
Applicmt _ -
NOTICE I CA L afar making Nis Cenificam of Eacmption,you slmuld
become
sublmrto r er Compensation movidona of the GWr.Code,you man
forthwith comply such provisions.,this permitshull W doemedemoked. _
CONSTRUCTION LENDING AGENCY s
-.Q Q I hereby aRiw Na them is a construction lending agency forthe performance of
the work for which this permit is issued(Sm.3097,Civ.C.)
a .a
Leaders
y Lenders Address
W , e 1 unify tut 1 have mad this application and sum Nat the above infowation is
Owcorrect.l agree to comply with all city and county ordinances sad aunt laws misting to
V O construction,consction,and hereby authome referesenumm
tivfthis city enter upon the
aWv.-mentioned properly for inspection Purpose. s
LL (r (We)agree to ave,indemnify and kapwn ri
halethe City of Culano against '
0 V liabilities,judgmentacals and apmsea which may in my wry accmeafialnn said City
^fix W ',consequence tef the grana hof Nis r
pemit.
[ti Q !APPLICANT ' ST DS AND WILLC� ITII ALLNM11Nf A
C.7 Z SOURCER 1 IO S 4 V 4Date ��yg�)
ti gtuntr. fApphcant/C I'?—g e) • 2 n
Si
RDOUS MATERIALS DISCLOSUA. dy�/ / J
Will the applicenn rfmure Wilding mcatuart store or hurdle haradous material Re-roofs -
as defined by the Cuperino Municipal Cole.Chapter 9.12,and the Health and Safety „
Code,Section]5532007 •Type of Roof' '
❑Yes no - -
Willtheaplicantorfor=buildingMmu;rxet use wa;Pmn,indn;raswhich All roofs shall be inspectedprior to any roofing material being
emit hamdcus air comenitwn ax defined by the Bay Area Air Quality Management installed. If a roof is Installed without first,obtaining an inspection
Yes I agree to remove all new materials for inspection. Applicant
ve re
Q �,p'in�. � d
t/ shaad thc herandmn materia,requirement miler Chapter 695 of he Cali- un ersta0 will comply with all non point source regulations.
amu Health&safety code.Sectio.25505,25533 and 23534.I andenund Net if the —
buildingdoes not cu sly have a tribal that it is my milensibility to malty 0e occupant /
of
the regmq s hie mustWn tpdor h,issuance of a Certificate of Occupancy. q
Sign urs of Date
Ow m m 'nr Done -
All-roof coverings to be Class"B"or better
OFFICE