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00040027 CITY OF CUPERTINO - PERMIT NO, BUILDING DIVISION PERMIT CONTRACTOR LN'FOg R(MATIOg N: ©�O y 0 a r BUILUINCI AUURE55: �`+' G� / � v SANI'1'ARYNO. ' APPL[I ATICO-NISUBMMAL DATE OWN SNA Vn��`T/f �a / J �O � �-(J ��fn�•r /9 �„/ �S�9 �L����•NIJ//�L.1 NIC CONTROL# HONE: - - ❑' I , RCHITEC MNGINEER _ •—v IlyOr O BULDINOr12RM 04 LICENSED m ddd z O H LICENSED CONTRACTOR'S DECLARATION 1 Wei.Bron tial 1 w licemd mover ryodsimr of Chmtu 9 frommeneing Job Description =E� Cith Salion 7000)ofDivl,ion3oft Bmiwssu ftfeaions Code,admylic,nwis o Iicers eaM e, 1 0",/ J / 9jeffM Dem Contra a O SI ARCHO'ECTS DECLARATION 1 understand my plans shall h used a Public rccads. �Q/u� a a-•' ./YP�!/ /'pe � •J �d 0 �� . yy�rcQ 6 6 Q K LICe115[d professional OWNER-BUILDER DECLARATION t• >' 1 M1eaby.Seal nn 1 em exempt Gum be Contractors dLic y c Lew co the fallowing maw,.Section c mnB.Business and Professions Cuda:Any city m county Wnlen nitsiief aped.nuC016Wq.'li Imprama pinulan,ears.sig edaWc1uR •S Ft.Floor Area - Valuation ptior to is iamuncc,alw rzquirta the appEcant(asan pemthwfileasigad mtement kl' OU slut he is licensed pursuant to de provisions of be Cona¢mre Liana law(Claph r 9 (commencing win section 70007 ofDivision 3 of the Business and Prohnsiom Code)or APN NbOccu ane T do, he is camp,therefrom and the baeir for the allegd exemptionNumber e p .Any violation of ' p Y Y Section 1031.5 by any th"Heant for a permit subjeets the applicant to a civil prey ty or 3�6' 7 n??? Sfi pt mom than five hundred dollars($300). - !� - I,as..of the propeny,m by,smployaa with wages m their salerompewtion, - Required Inspections coin do Ue work,aM hemoom a isnm intended molraed fmsale(See Im.Business and Professions Code:The Contractor's License law does net apply to an au mof , property who builds or improves thereon,std who does men work himself or through his own employees,provided that such improvements am not intended or offered for We.If,however.the building or improvement is sold within one year of oompletion,the ..Wiltlu will levo tiu burden of govin{Un he old not build a impom fm Pur- pose of ale). ❑hat th er of the property,am sines and Prostin.CIU hawed cammuo n - mavudthewnot apply w.w.f endrly who but&.,O'Ibr aantractm'n U- m. cents Law,does not apply m m owner ofpropmey who sed p or ant in the thersoa,and who contracts mvc famch projau with acontnnor(q licensed purtuanlmthe Contractors I Erma new. El 1 am exempt seder Sec. .B&P C for this rtnan S ,. caner, ' Data WORKER'S COMPENSATIONDECLARATION �OO• 1 hereby rm en W ffrander py of perjury me of the following declarations: I thousand!will meinain aCenifl.,..ofeonsmt m saiGinsum for WakesCompen- tim,as Provided for by Section 3100 of the labor Code,for the performance of me ink for which this permit is issued. Ej 1 have ad will maintain Winkel s Compenasion I..,.as apuircd by Swine u 3100 of one,Labor Code,for the performance of the work for which this permit u issued, My taker a�pnIna 1ft rNoY�y612- n CEAMRCATErOF FYPMPTION FROM WORKERS' COMPENSATION INSURANCE ('(Lis section mieedna be emitimd ifthe Pconit is foronchummol doll.(SIM) - ear lesa.) ' .wempLloy myy Uparstoinn inmyarar marcrc a ofasto oraorcr wwhbijcuhtlhmisthpee Wa tim'C=phanl- AppTawsofCdifomeDa licant l - Can Nmere bi APPW a Work If,afar making this wirier al,ofLaborExemption,you should ' hecome scomp to the Workers Compensation provisions or Ue Labor Cade,you run •• forthwith comely with sufh provisions ear this permit shell be dated rooked. , CONSTRUCTION LENDING AGENCY Q I hereby,affirm thu them isn comuuctlon leMingagmcy for tM pernmunce of 'TJ- ti the work for which his permit ie issued(Sec.3091,Civ.C.) - Fy Leder',Name '. . a lands Addrta W p - 1 ou ify Un 1 have red this applicnion ad swe that the above i,arnsure,is z corral.I agree to comply with all riry ad runty on imnus motion,laws rearing ro + _ building construction,and hi aby athodse rtprtanmivo ofthiscity to anew upon the V abo4amentiond property for inspection purpaas W - (We)agree to ave,indemnify and kap lurmlws the City of Cupertino against - V Inti ihum,judgmenls,rowsand expenses which may in my waywcme against aid City - } W In consequence of the granting of Uie permin. - [-� N APPLICANT UNDERSTANDS A WILL COMPLY WIT If ALL NON-POINT - Cj 1 SOURCE REGULATIONS. Signs lnayrApprra,trco RDOI D.m r/ HAl,for. MATERIALS D15CLOSURIi WilltieeCupertino Muni thudding rccupantnaeaandse Health smmenal Re-roofs .. a defnd io the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety - caac,saranzss3z(.)?, , // Type of Roof - ❑Yes Will the applicant or fumy building acupml use equipment or dc,ekar which All roofs shall'be inspected prior to an� roofing material being r Ihawdousair conumivntsasdefindbythe Bay AmaAir QalityManagement installed. If a roof is installed without test obtaining an inspection ❑Yes I ree to remove all new materials for inspection. Applicant. . TJ rvo a g Ihave dmahuant.r;iaarefiiementsunderChalker6.95oftheC.h• und maerstands and will comply with all non point'source regulations. .fame Health&Safny Code,Sections 25505.25533 and 25530.1 udersad that if the ') building does trot currently have a human,this it i,my responsibility to mwrify dm,resolvent 3_ �. „•„ra5 of the requhemems which must be met prior no issuance of a Certificate of Occupancy. L.V✓ nature ofAppli -" Dat Owner or eu a n Dau , All roof coverings to be Class`B"or better OFFICE