00040109 . CITY OF.CUPERTINO - `, -'PERMIT NO.`
Buttomcnrvtston PERMIT (90 OR t ` AaTIOg ^j' `-�h o ( O
BUIIDING AD DRE55: - - V
S TEARY NO, `� APPLICATION SUBMITTAL DATE
OWNER'S NAME:.��/ /,//I\I -
\ ONTROL# v ,.
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NIC
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1' 2 7�- O .. Bu115 .err I`T N
AKCHITECT/ENG UTCIVI"""
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• LICENSEDCONTRACTORSDECLARATION^ '
ZG i hereby affirm mat I an licensed under provisions of Chapter 9(consummatingJob Description,
w wonSemon 9000)o ry fD ,sion 3 afore Business and PmfessmvCode,and by license'
in fall ro=and effect13
L' se Class L,P.N
is u.y D 1J11,tif,sAAg% CWture - —A WAS ..� �7/CEJ lf.,
O Q ARCHITECTS DECLARATION, ^✓✓,
1 undershoot my plans shall W used as public meads
s
O LiOniaed Pmrmewhal
m
OWNER-BUILDER DER DECLARATION
f hereby aRnn the,1 Rare the Commutes License taw for the A /� po %>o � A ' J �^ �fs,v o e '�,S�'V•
E F following season:fgauon t I am-exempt 5 Business and heProfessionso Cade Any city w county ,V _J 'v L9r+nV'v —
which require¢a permit to comrwa,cher;improve,demolish,or repair any
smrrnue -
d a� Sq.FE.Floor Area ' Valuation���
Red he
itsextreme,
pursuant
requires thevisionantforsuch Cmunsumutmia.Law(Clnamed 9 /Vr
thaiheislicemeth Section m Xy.[D ion3NeaButinta'¢License Lew(C Ma)c, - V
them
hem a is intg with Section and th Diaision3 the al eged campt on.Anlmr Cade)or - -
' mane is exempt Nrrerrom old me base for me wigid exemption.nmr,viamen er ' !�.' APN Number Occupancy Type
Section]031.5 by any applicant for permit mbjecm the applicanuo a civil penalty of s 7J `2G.B� + 6'�C
not more men Eve hundred dollen(SSW). : ". ' ' ✓ • /
❑Lar owner of dm property,or mY employees with wages ere Neir solecompemN,in. Required Inspections - •.
will dome work.aMthesuucture is not imendetl or offered for sale(Sm.7W.Business '
and Professions Code:
Contractor.The Contractor.License law dm ow
close not apply sn owner of
'proprny who builds or improve¢mareon,and who does such work himself or through - ♦/ f� p j uM/3J/✓ •.
his own employee,provided that such improvements are not intended a offered for L/I� r\r-/OD 2, P
sen lf.hewer willh Wilde burden fpiomng that he lid rum Wild
or Improve
for
ow ufassider will have me burden of pmvine that he did not Wild or improve for Pur- T +`
pose asale.). -
❑L u owner of we property,am exclusively remaining with licensed contractors to 1 C e e� �J°•�UM$� J�'l.�C/l�f}N/[/¢L .EL1a'L�72/CJJ .
compact the project(Sec.]M6,Business and Pmreismor Cade:)The Commmuce.
Li-came law does not apply m an owner of property who Wilds or improves thereon,aM
whms for such Prolecu wimecontnmor(s)IiunaW punuenlmme Contrecmis, "„I '✓IF
License
se LaLaw. e .
p lam exemp underSa. ,B&PCfer Ws reason
'weer 'Dam
WORKERS COMPENSATION DECLARATION
therebyaffirmunderpemltylcpejuryoneordfinsummg oe er''sC
Ihave endde fimbineCion37Mf the etre elf.forte Work sCofm - j
anion as which this
fm by Section 3]00 f m Lebo Code,f m Performance f me ,/ ) Al '
for whidM1 rets Parma is issued. ” /icy.S�J<rt'
have and or or,fmaintain Worker's fm Comer th n Irk for which
as req 'red by Sat
ion
.fffie Labor Code for Imen.omunceorm ark for wh ch lh aprmmt's sued r�/( qn /�•fSrn ��N'[. -
.MYWorker'sCompcnsetanl�suren <amttand Pnliry pumper O pp " +/r/�//-f`'/ •�"k;,. - -
Lamer s.'TTIRCA C/I 6N No / 3 7/ / / _ '• �/ •.
CERTIFICATEOF %EM iNN FROM ERS
COMP replete ON INSURANCE - (�'d��U., f. �'I L•• s f 'I,
(Th section need nm be complemdif me pemdt is for one huvdreddollan(S100) V {� • vqA-
Icertify that inthe perfams.ofthe work for which Nis permitis issued,l Asill ! V
not employ any Peron in any manner so as to hmnine subject to the Workem'Comps
' Applicator
ser, els sof Cclion Du. - C/./,/R,L,S•
Applr ., r /Y
NOTICE TO APPLICANT If far maY ng'Nis Cetufinm f ExemPuon You h Id• s ,-
becone,mbjmt m me Worricers Compensation pmvisionx of Ene Labor Cade,you must 741Z ` -
foMwith comply wim such provisions or this perms shell W domed mvokW. 1
_ CONSTRUCTION LENDING AGENCY
0 0 ' I hmcbyafftin the there is acumt enon lending agency forthe performance of.
F the work for which this Fromm is issued(Sec.3099,Cit.C)
Lender's Name
Le"tex Addrst :N
'tri Q I certify Ener 1 hive read this application and state that the above information is - Y1 oivr 01*46
4 correct,l agree to wmwimply all city aid county ordinances and sate laws relating in rl
z budding conmucdom,and hereby audience-repieeentativemfm's city to enter upon me
.0 - .. ,
above me e)ogre propene for impaction steep ea. , '. •.
W'F (We)agrees,cave,indemnify and kith hay in an me City o Cupertino against t
.0 �) Ilabilse¢,jnso,ofd,gnmin,.f tand his
pionorhtheyinany way ecerim agilna(said City _ ,i ,.
inconsequence of the STAN oforis pWILL ! ,
,� z 'APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON-MINT
V z SOURCE REGULATIONS.
Signature of ApplicanUConurectm
HAZARDOUS MATERIALS DISCLOSURE -
WilltheapplicantorfutureWildingoccupant store or handle woundous memo&' Re-roofs'
ceddin rill b the Colima.
oli no Municipal Code,Chapter 9.12,and the OttHealth and Safety Type of Roof
El Yea . .'.
All roofs shall be,inspected prior,to an ,roofing inaterial-being
Will me applicant or future Wilding occupant use equipment or devices which , yy
oroithis';and...sir contminats tm definW by the Bay Arca Air Quality Managimem installed. If a roof is Instal led Without fitst obtaining an inspection
I agree move all new materials for inspection. Applicant '
1.
❑Yea '. 0��..,. .. ,.. . d
a art ars nd n Zorup,
ith all non point"source regulations.
I have read me haaadous nmmnas requirements u" Chapter 6.95 of du Call
fomes Health R Safety Code,Securrat 25505,M533 and 25536 I demand mise f the
WildingdmsnmcunentlyheveamnantmairnmymspnsiMlityronaifytheo¢hpam'
of mereyo,nowluchmustbemnpnormusumceofaCmificateof Occdpomy.
Signature of Applicant Dat
r t u w n ted agent
- I - All roof coverings to be Class"B"or better -
OFFICE