B 0659 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CTTY DI CUPERTINO BUDDING-ELECTRICAL cnnn' �OP'F.AMI-NO. ^4 ^ ^ e
BUILDING DIVISION APPLICATTON/PERMTT PLUMBING-MECHANICAL PROJECT
ICHANICAL �doo0j 6 G �Li C/�l7—LJLJl•
• BUDDING PROJECT IDENTIFICATION
HUE.DINGADDRESS: SANITARY NO. APPLICATIONSUBMIpTALQD,A
�c376D RI?� TFI wq. ' C /
y A 'S NAME: PHONE: CONTRACTOR'S NAME: I LIC NO: Z_
04�7¢- _ NIC CONTROL k
.RCHITECT/ENG R:
'C N`
ADDRESS: ❑
2-9
CONTACT: PHONE; BUILDING PERMIT INFO
--360t6 O ❑ Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S o blocam
DECLARATION QTY ELECTRIC PERMIT FEE
I hereby efbrm Msn ga
e[I eased undo providays of Chapter 9(covwcivg JOB DESCRIPTION
a'Z withllto=ande efDiviAon3of the Hueineu and Profeaions Code,endmylicenaei.
tOtpO fu..ausndeffect PERMIT ISSUANCE FDWL [I KITCHEN REMODEL
�U Latetae Cleat/ Cm Ar
ate, Date Convector APPLIANCES-RESIDENTLU. AD�r ❑PLUMBING RE-PIPE
ate-,pj ARCHTTECCS DECLARATIONPANELS ❑MULTI-UNIT ❑STRUCTURAL
I undentend my plans shall be used as public mucic PANELS
4t.1a UP 70200AMPs ❑INTERIOR ❑CHIMNEY REPAIR
[?. u] Licenced Prefeuional 301.1"AMPS IMPROVEMENT �SWIMMUJO POOLS
•.-.lI OWNER-BUB,DER$E Ce ContrION OVER 1000 AMPS ❑BATH REMODEL/REPAUI EIDEMOLITION
6 I hereby affirm that I am mempt from the Cssion o Ligase Law for the a GL) whichfollowre meson. anent t 7031-5,Business end ere.dedone Code:Any city structure counry SIGNS ELECTRICAL OTHER
Wp whichinuhese.,alsoreuirewct alter,improve,h permiitt orrepair edamo
primtoiuiuued also rtto'he the eppgunt far Cchpemul tofiusnouLw(Ch mem SPECIAL QIRGDITMtI$G.
that he is gmrctl pursuant m the provisions of the a Easiness an mss Law(Chapter9
(commencing with Sectlon]000)ofDivicion3of the Busmea asci Prafa.iom Code)or TEMP,METER OR POL6INST. '
n C but he k vempt themtrom and Ute baso for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLMON
44.• seNon]031.5 by any epp6cmtt for a permit aubjate Ne eppticent to a Gvil penNry of POWER DEVICES ❑TENANT El FOOD SERVICfi
not more ohm five hundred dogov(gS00). IMPROVEMENT
Bothe woof Ute the rutgmmy employee wirhwya as.1.(Sao. 1p,i,Business
SWIMMING ELECTRIC ❑OTHER
m and Pressilons Cade:The Cmurn es License Law does or apply to an owner of OUTLETS-SWITCHES-FLCTURFS
p' property,who builds or impmvm ohercon,and who docs such work himself or through
Ise own employees,provided that such impmvemenu arc not inteodcd or Warned for NEW RESIDENTIAL EIECTR SQ FT.
.0..If,however,the bugdiug or improvement iasold within one yeuofcomphdam,the SQ.FL FLOOR AREA $/SQ.FT.
owner-builder will have the burden of proving tort be did not build or improve for put-
consLUA Am wner
rte
, oof the property,,B reclusively contracting with:i no Cconmocu'.l. TOTAL:
construe[the ryvjttt(Ser.]044,Business end Pmfeevions Code:)The Contracmr's Li-
cense Law don not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE Q
who contacts for stark projects with a contractods)licensed pmsumo to the Contractor's
I asn an cx
A11LIcempo under Sm. ,B&P C for U.a reason PERMIT ISSUANCE Z !!
,ay ALTER-DRAW&VENT-WATER(EA) VALUATION
Dae
WORKER'S LbMPffNSAfOECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm uMer penNry of perjury o ofthefollowingdecleredons: O O
:,:'��Iheve and will mmnWna CeniOntsnfCamatmself-Ivawe fm Workels Compen- DRAINS-FLOOR ROOF,AREA,COND,
salon,an provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTIO
work for which this permit is issued. - FIXTURES-PER TRAP Z
71I have and will maintalo Workers Competuedon Insumnee,ae requbed by Section
3700ofthe Labor Cvdejorthepufnsmence ofthewmkfmwhicb thispvmitisissued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP "NMy Worker's Compensation Insurance carrier and Policy number ere:
Cartier. Policy N., GAS-EA.SYSTEM-OVER4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 1�
COMPENSATMNINSURANCE OREASEMDUSTRL WASTE INTERCEPTOR BU NODNISION FEES
(This notion need not be completed ifthe permit is for one handed dollen(5100) GREASE TRAP
or Ins.[ PLANCHECK
IcmifyUst in the performance of the work for which this pemsl is issued,I shall SEWER-SANTIARY-STORM EA.300 FT. �
not employ any person in any mumu so as to become subject to the Workers'Compen- ENE
O Z" x
action Law.of Cal'f omit/.Date
WATER HEATER W/VENT/ELECTR
y O Applicant GRA MNOTICE
�Cyy raj) Woome subject
pPPLhCANMe Worker's
ork V,Co making thisCertificatethe
Exemption,yen should WATER SYSTEM(1REATINO
ICryr become euomp w the W 6 r previsions
or s erndt,om of the labor Code,you most SOILS
forthwith comply with ouch provisions or Ws penrso shall be dermad revoked. WATER SERVICE
� z CONSTRUCI]ONLENOINGAGENCY NEW RESIDENTIAL PLM3. SQ,Fr. P
C.IO [hereby affirm that there iia convection lending agency forthe performance of Dete Receipt#
{3s t+ the work for which the.emit Iv issued(Ser.3097,Ci,C.)
0 U LLenccds dae:Name T,
LQ Icomfyt TOTAL:
LL I ratify that I hove mod this application and state that the above information is BUILDING
!/) correct.I agree to comply with all city and county on innrtces and state laws raising to QTY, MECHANICAL PERMIT FEER7 building construction,and hereby authorize represve.of Uds city to enter upon the SEISMIC E'�
mnu
above-mentioned property,for inspection purposes. PERMIT ISSUANCE
(We)agree m save,ivdenmify and keep haaldn.the City of Cupertino against E B i.
liabilities judgments,costs and expense which may In any w,accrue agunm.aid City ALTER ORADD TO MECH.
in consequence of the grand,of Nis permit PLO FEE s
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGSWI'I(T010,000 LPM)
SOURCE REGULATIONS. MECCAL FEE d
ABR HANDLING UNIT(OVER 10,000 CFM)
CONS UCTION TAX
ignmue ofApplic UConloctor Dam EXHAUST HOOD(W/DUCT)
110
HAZARDOUS MATERIALS DISCLOSURE HOUSIN MITIGATION FEE
Will the applicant orfumrc building occupentsmrc or handle hmerdous material HE,aTNO UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9,13,end the Health and Safety
de,Section 25532(a)] HEATING UNIT(OVER 10LOW BTU)
r7 Y. ❑No VENTILATION FAN(SINGLE RESM) PAID
Data Rmeipt#
Will the air emast or future building by the Be,nae equipment of denim which BOH PR-COMP 19 OR IW,000 B
_+ est hezudow e'er conleminans u defined by the BArca Air Quality Management O TUI
SBmm] roraL:
❑Yat ❑No BOILER-COMP(OVER 100,000 BTU) .t,
I have mad the locations mated.1,rcquiremenu under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forme Health&Safety Code,Sectlons 35505,35533 and 25534.1 understand that V Ute NEW RESIDENTIAL MECH. SQ.FT. ,_ s!�]00building don.menc em,heve.mnaat that I:b my maNnsibOEry m vofify the occupant 2�
offfi=mts Scm.tbannot,ri aaumce ofa Certificate of Occuper y.
O vaeurhoriz ye
Data TOTAL: ISSUED BN
nc r_trr_
POSfTHIS CARD NEA I'OF BUILDING
CITY OF CUPERTINO P�NO,
BU11,D1NDIVISION DMS'
ON BUILDING PROJ 7— --7
ECTIDENTIFICX;�.
BUILDINGADDICESS: SARY NO. APPLICATION SUBMITTAL DA
7 f,
R"'Alp. 'NPIF4 -4: �/�R LTC NO:
S� NIC CONTROL#
C DCT Et
�N LICNQ: ADDRESS
Ilk
BUILDING PERMIT INFO
INSPECTIONS DATE INSPEC. 0 Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB b CH
El El E El
FOUNDATIOM/PBERS/H.D.S. INSPECTION RECORD
NOTE: ALL GRADING AND DRAINAGE LIFER GROUND _u'7 � JOB DESCRIPTION
PAD/SETBACK-CERT - SHALL BE INSTALLED TO COMPLY WITH 0 KITCHEN REMODEL
'fjo CITY OF [I ADDITION 0 PLUMBING II/ THE APPROVED PLANS AND I
GARAGE SLABS/PRFOUNITI6�',i?-oj 65 �CUPERTINO STANDARDS. OMULTI-UNIT EISTRUCTURAL .
MODIFICATION_
POUR NO CONCRETE UNTIL ABOVE HAS BEENlIGNED, TO ARRANGE INSPECTION ED INTERIOR D CIE]MNEY REPAIR
UNDERGROUND/SLAB NS -PM 4.30-P.M) 0 SWIMMING POOLS
-PM) 0 BATH REMODEUREPAIR 11 DEMOLITION
PLUMBING 777-3228 MONDAY TO FRIDAY 24 HO URS B E- []OTHER
ELECTRICAL FORE REQUIRED INSPECTION.JOB ADDRESS
DO NOT POUR FLOOR UNTIL ABOVE HAS BEEN SIGNED AND PERMIT#ARE NEEDED WHEN PHONING. COMMERCIAL
PLUMBING ATTENTION CONTRACTORS: El NEW BLDGIADDITION 11 DEMOLITION
29L�:�O PERSON(S)SHALL PERFORM WORK ON 0 TENWr El FOOD SERVICE
0--o
MECHANICAL 'Z-/ —f,INL THIS JOB SITE WITHOUT BEING IN COM- IMPROVEMENT
ELECTRICAL PLIANCE WITH WORKERS'COMPENSATION El OTHER
FRAMING VENTS RANCE REQUIREMENTS.
INSULATION SPECTION SPECIAL INSPECTION REQUIRED E] DATE ENSP.
PLACE NO SUBFLOOR UNTIL ABOVE HA q BEEN IGNED
ROOF SHEATHIDIAPHPAM 0 le-e
PLUMBING
ir
TUBS&SHOWER PAN
ECHANICAL
LECTRICALIPOOL BOND '
FRAMING/STAIRS/E.EGRESY,49-,-'e,-,-),, -
INSULATION/VENTILATION
COVER NO WORK UNTIL ABOVE HAS BEEN SIGNED
EXTERIAL SHEAR/HoLDDOWN A
INTERIOR SHEARMOLD DOWN
SHEETWROCK/SHEETROCK SHIA
EXTERIOR LATH[W-SCREED
SHOWER LATH
NO TAPE OR PLASTER UNTIL ABOVE HAS BEEN SI
SCRATCH COAT Ik?
SEWER/WATER /0
TEMPORARY APPROVALS
OCCUPANCY
ELECTRICAL 12— fg?—
GAS
FINALS
GASSM
T
GAS TEST /,),4) cF
OCCUPANCY
Sr
GRADE
FIRE
HANDICAP
ELECTRICAL
FUIZING t Iry
MECHANICAL
ENERGY CERTIFICATE OF OCCUPANCY❑
VISUAL FINAL ONLY
IMPORTANT: ISSUANCE DATE -7� -,n
BUILDING BUILDING IS
PERMITTED:! JSS N� BUILD_
'�v
OCCUPANCY OF BUILDING IS NOT PERMITTED: PLEASE READ REVERSE
UNTIL BUILDING FINAL IS SIGNED B'Y'h'U1jL"D CALLING FOR FINAL INSPECTION!!
, S IDE BEFORE
INSPECTOR. IRSUEDBY,
APPLICANT'S Pn.RTINr mpy
CITY OF CUPERTINO gA';r *�.e w"t�9tt.,Js T,. ,y(" - nr PERnm'No.
BUILDING DIVLSION PERNIIT �^C. Np�T a T�® ��,, WIN . �Q� le� 'J-o <) 1 y' 11
eU11-DWOADDAESS:
SANITARYNO. C NS p1 DAT
gN
S
M 46, Z NIC CONTROL*
PH
%- ARCHITECT/ENGWEER a/`�g"�� pf/�� n t:".�x:7dr`:����4i'iafii.tiwo ren�lri!mmo'r��,rat'dt`
�ZDo � J•Te' "_ �J
LICENSED CONTRACTOR'S DECLARATION
z hveby affirm that I me licenced under provisions of Chapter 9(mmmmdng O Job Description
wiN Section]00p)ofDivulon 3 ofrhe Bu,inen end Profeas(oas Code,W my tissue is
oin fullfmu end effect �(a�./h .
Liceme Cleo LIL.N C ( V
It,� Dole Con¢actm
O1 ARCHITECTS DE ON
N---7777 1 mdenwnd my plans shell be ued as public rrmrd,
6�
to Manteca!Profe.u..I
OWNER-BUILDER DECLARATION
I busby sffrrn Nat I on,uempt frmn the Commune,Licenm Lew,for the
P following eemv.(Section 7031.5,Eminent and profession Code:My city m county
$ which,mryima a Fermis m marem t.also,Improve,demolish,or repair any mumum S Ft.Floor Area
prior..its ismengelm mquims theeppEcent forsab permit m felecelgeed,wlvmnr q• 8 valuatlo
that he is licensed pusmnt to the pmvidms of the Consomor,Lice a U.(Chep(a 9
(eovmmcing with Samo 7000)of Divider 3 ofdm Busmu,and Profeuioru Cade)m
the[he is aevWt therefrom W we basis for the alleged umnpdon.Any violation of APN Number `Occupancy Type
Section 7031.5 by my Applicant for a permit subjects the Appiwatv to a civil Tommy of _rj
me Nm
not mfive hundred dollars(3500). V
L as owner of Ne pro(wry,maty nnploygs wiW wgu u weirsolc eompemWom Required Inspections
will do the work,and the strum m is not dotards m offered fm mie(Sao,7011,Emma.
and Prowulom Cade:The Contractor's Ligate Law does ret Apply m m owner of
property who builds m lmprova I.,Arid wbv data arch want,Hunagmuo
dug„
I .......loy..,provided that such imprvvemrnu ate von baevdm or offered fm
sec.lf,M1.c.,dumilding orbaprovcmmt h mid wiJdn meyuro(m n godsm,rhe
owmr4wilder will have the burdrn of proving lhel he did nor build or improve for ,pur-
pose of ole.).
❑1,of owns of the property,w exclusively camowdng with thermal mvvactors to
con,wm the project(Sec.7044,Budnrn and Pmfassiom Code)The Cam arm's U.
mom Law data nm apply of an owvu of propmty who builds on,impmvu therms,and
who."at,far soul project,with a contractor(,)license pmm.m Ne Coma,,
Licare U.
❑I un ccempg under Sa. ,B d P C fm this reason
p m� N 4 ��
wnery 4'WORKER'S COMI'PNSA N DECLARATION
I hereby affirm under pmdry of perjury one of the following dech ndmu:
❑Iheve and for
by eCurt37M of she Lmoo cdt in furefmWmkerace of she
radon,u provided(pa by Sadon 3700 of Ilse Lebon Code,for we performance of she
' work fm which Nie permit is lamed. '
❑1 have and will mdnuin Worker's Compensation buuranq of requiteby Station
3700 ofrhe Ubm Code,for the per m mce of the workfm which My permitd Is issued.
My Worta's Cmvpense[ion Insurance coda and Poliry Dumber
r..,;¢ Policy FROM OF COMPENSATION
INN FROM WORKERS'
COMPENSATION WSURANCE
(This satlon naeanlbecompleled ifwe Pvmitiefo onehuvdeddollan(SIM
t m.)
I wti%dul iv the partmmmceof the work fmwhich thispermil i,i,mLIsbell
noempty
not employ any person inhtany manna sec Ano become aubJat m the Warken'Compcn- I
rationant of CelifmniA.Dam
Appbecame
NOTICE TO APPLICANT.IC after making dale Certificnc of Esempdm,you should
becorne mbjemm it Wohero Coons ,this pmvhion,o e da Ubm Code,yon mon
fortM1wiw comply with mcM1 provisions or this permit cM1ell be same evoked. �
CONSTRUCTION I,ENDWO AGENCY
0 l hereby slion then Nue i,a mmoucdon lmdingagmryfar Ne pufformmce of
rhm e wonodss Nuns for which Nis pounds 1,lamed(Sec.3091,My C)
[y' no
p� I<rrderI Address
w Q I onedly Wat 1 hove rite dela,and a. and sonic diet Ne above laws
mmm ie
U 0 conac 1 ansa en comply hm all th and mm o &n os afflatus ww, Woe c
.1nov.ngconnumiamanbIbahmmumn,n reprurnwdva of tial,cityto msaupov rho
W � above-mmeonepropervypforbupecdon sampIm fA
y (We)ages m ave,idem,%and kith hemdus the City mCupertino agony
fJ ba"mou,jmgmmu,meat end of
pesmuniich rosy in my wayamue egaW,l add City
7t [tj in PLICAMT NTEgruntingof dal,pcmdt
fFUyr APPLICANL UNDERSTANDS AND WILL COMPLY WITH ALL NON-MINT
SO REGUUTI N5.
hf j=2 rid
Slgmwe Of Appfttar Contramor Dow .
HAZARDOUS MATERIALS SIS=SURE
Will dmappliuntorfumre building oaupmtnoeor handle huudou,mvwdd Re-roofs
as defined by the Cupertino Muniripa[Coda.chapter 9.12.and Ne Health and Safety ,...�
mea.section 25,32{.>a Type of Roof / / X ��
❑Yn No
Will
we app4cant or future Wilding ocmpmt uac equipment or device,which All roofs shall be inspected prior to any roofing material being.
mit hasrdou eh mauarmanue,defiucd bytm Bay Arca Ah Qm1hy Management installed. If a roof is Installed without first obtaining an inspection
Drnn`t2 g
❑Yes ANN. I agree to remove all new materials for inspection. Applicant
c -
.r. I have tendthe M1umdoa,m terel,m4nnmmu cautu Chapterd.95nfdeCali. unde tands and will comply with all non point source regulations.
fomw Health 4 Safety Cade,Sections,25505,35533 and 25534.1 mdemmd that if the
buitdingd fam"dyhaveesment,shat itis ymspondbilitymoold,the orcupmt
of the nml 'chh.er/'t he mfT pdorw uhrQ,ce ofe Cenifi of Qfcu_pY.
own nra.mm m" /Dewy✓ Signature of Applicant Date
All roof coverings to be Class"B"or better
/CITY OF
oINO COIVTRAC*�-.TOR INFORMA'iTO+ N PERMIT NO.
/ PERMIT ,TMI, �Y l
EDgpwO aDnREss:
r
// � � '�/A t ] !� �i.:�' � f,y t,4..] •� SANITARY NO, PLICA�I(1�O-N S(llBhll'ITAL DA.
WN
/• OER's NAME: .. `
f/ ''//f/!^l•h'lt %'�.` .Nr •'':'7""I .:!a"` .'"'...- ' ' I '� we CONTROL#
El
ARCMECT/ENGMERM {l + -;A'41'
ly C1. /
NOTES µ'
jJob Description
a
� g
<0
a�
Iry_y
P q
- Sq.Ft.Floor ea Valuation ;r tom. .,;
APN Number Occu- anc e
P y�P
Required Inspectionsr 40
. .
VVvv
S U �
2,5
,
) z
� Q
) z
> o
Re-roofs
Type of Roof
All roofs shall be inspected prior to any roofing material being
installed. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
un ,rstands and will comply with all non point source regulations.
r ,_ L
Signature of Applicant Date
All roof coverings to be Class"B"or better
APPLICANT'S POSTING COPY
6
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
l
• HUBDING ADDRESS: PERMIT NO.
"'SNM�EO ARATA WAY APPLICATION.,$).m,.,.M 1.4
_ : PHONE: KttG1G�i1O1
= MARTINEZ, RICHARD SAN anY�Q �1E,C`pNTBQi NO 4BUILDING PERMIT
l�INFO
00 ARCHI7'ECTIENGINEER: - BLDG ELECT PLUMB MECH
z LICENSED CONTRACTOR'S DECLARATION Job Description
Z�3 1 hereby affirm that I she licensed under provision.of Chapter 9(commencing
vD v� with Section 7000)of Division 3 of the Business•nd Pmfenions Codgand myrica]..
I.in full force and affect
o U Lieenae Class Lie.N
Dna O
cium" or
Ve u ARCHITECT'S DECLARATION
toto 0aj lunderstand myplane shelf beused eaPublic records TEMPORARY POWER
ec00Licensed Pref=si...I
P1 m OWNER-BUILDER DECLARATION
C� I hereby°ff that I an,Bounce,
from the Convenor's License Low for the
aax
following ng ions,.(Section 7031$Business n Professions Code:Any city or county -
E❑ which mguims•permit m conttmet,alter,improve,demolish,or repair on,swcmre
fthrv3m pnortoi4 lasered,°Intent to res me applicant(Drsuch permit to filea.igned]creme.
C.morhtchn, itpSeed.im00).dDlAdonfuseConuacrosLicenseIaw...Cer9 Sq. Ft.Floor Area Valuation
(commencing with Ssdon om andf .basis 3 of m=Business and.r.An vi Code)
or thatio is 31.5 b therefrom and m=buns for me alleged,11..t to Any violation
of Section Hunt v any•relic•]]for s p=mut subjecb the appllcons so a civil penalty
of not more man five hundred amlars(gSDo). AIN Number Occupancy�'�}rpe
DI,sownerofine property,mnn employe]withwagese thairsole compensation, 11
will do the work,and due swcsum is Out intended or ofered for N=(See.7044,
Business and Professions Code:The Connector's License Law does not apply to an ;30equired Inspections
owner of progeny Who builds or improves theraen,and who dos such work himself 37501561 ,
�]I
w through his own employee•.provided that each Improvement are not intended Or
offered for sale.If,hDWea'er,the building or improvement is sold width one year of
completion,be owner-buildswill have me burden of proving that he did out build or s
improve forpurposeafnile.). 304 — ROUGH ELECTRICAL
01,U...of The properry,am uclusively muV•cGng with Itemsed conmde.1. 501. — FINAL ELECTRICAL ENERGY
construct the pmjecs(Sec.7D ,Business and Pmfessimu Code)The Connector's 505 — FINAL ELECTRICAL
License Law done not apply to an owner of property who builds or improves thereon,
and who concocts for such project with a convector(.)licensed Puri to the
Co me.we,License Law.
❑I em exempt under 5 H&P C for mi.man"neo
WORI COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dslsreume: /
D I hove and will muntain a CarlIcam of Consent to self-insures for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit I.issued.
D 1 have and will maintain Worker's Compensation Insurance,s required by Section 00
3700 of the Labor Code,for she performance of the work for which this pemut is
issued.My Workers Compensuo t Insurance cortin and Policy number am:
Carer Policy No.:
CERTIFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be cdmpleed if the permit is for one hundred dollars
($100)miss.)
I certify that in the performance of the work for which tiers penrdt is issued,I
.hall not employ any person in any manner so s 10 became subject 10 the Workers'
Compensaudn Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Porkers Compensation provislons of the Labor Code,you must
o Q
forthwith comply with such Provisions or Nis permit shall be owned revoked
LLL!!!y��ytt4
CONSTRUCTION LENDING AGENCY
I binary affirm that then is a construction lending agency for the Performmce
of me work for which this permit is issued(Son.3097,Civ.CJ
Lender's Nome
z Lender's Address
V C 1 Carly tent 1 have mad this application and state that the above information is (3 01
W correct.1 agrc=to comply with all city and county mdinsces and ante laws relating
the abo building pr andherebyfor i paction j mp tiler. win of this city m enter upon
[� me above-mentioned progeny for inspersion purpose.
W es,judgments,°gree to,coat Indemnify and k hi h°my in me C'a of Cupmino against
V] liabilities,ZOPich cub and expense which may in any way accrue egoist said
City in consequence of m=g DS A of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON.POHJT Issued by: Dale
t is _a.O
sig re eyApplimn n ,r D.]= Re-roofs
HAIIARDOU RIALS DISCLOSURE
Will the applicant OV forme Willing Decupant]ort or handle hsatdos ounerid Type of Roof
as defined by dr=Cupertino Municipal Coda,Chapter R.12,and Ne Health and Safety
Coda Savor 25532(x)7
DYe. OND All roofs shall be inspected prior to any roofing material being installed.
Will she applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
;emit hit ardme Our eme ninents s defined by the Bay Anne Air Quality Management
Diam,tl7 Ye. ONO all new materials for inspection. Applicant understands and will comply with
_ all non-point source regulations.
-'' I have read the hsardou.material,mquium mete under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not our fly have a recent,that it is my responsibility to notify the -
octepst of the re is imams which mean be at innor to issuance of a Cauifim a of
°supe Signature of Applicant Date
wr reraumm;nedigent Dna All roof coverings to be Class "B"or better
t OFFICE