00040014CITY OF CUPERTINO • n PERMn'NO. -
smuotNcutvtst1.1. N PERMIT, •r CT® t •TIO 000} 001
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BUILDING ADDRFSS: I' 'f ✓�'
,COW `fCAa+.aN g�iA1 Gr�e r•• Y `/��, t/.. /a/I /
SANITARY NO APPLICATION SUBMITTAL DATE7970 'CN/C ONTROL#P-Is: nCL_ '16,957
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ARCHITECT/ENGINEER - .. { p - ?EUEDINCjPERMITpNI;O
DwaWz �'7 C,
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z0 4 ' O " LICENSED CONTRACTOR'S DECLARATION ,.
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= 0 •, I hcrcbY eRirm Nat 1 ate IicrnsW under provisions of Chapter 9 (commemivg Job Description
P Fm with Scctson7") of Division 3 mote Business and Professions Code.W my license 1.
4otuin force and <R
S p i D License CI ss Lic. # /(J
m 3 N Dam L ConDECL �* .
F � O Q ARCHITECTS DECLARAT VN 1 � I' 1 '
QO 1 undersand my pians shall be hand u public recmds ... r~ + ,[t a ✓� ... .
Licensed Profesaioml
d w OWNER-BUILDER DECLARATION t '
(: 1 hereby adifirm that I stn exempt from Ne Contractors License Law for the
f D
(011ennnig manam. (Section 7031.5. Business and professions Chau Any city m county,
' i m
which aq res a permit in construct .eller improve, demolish, or repam any snumure S Ft. PIOOr Area Valuation
prior m its issuance, als requires Ne applicant fmmich Formal m file asgnedeutemenr q' ^
that he is licensee Fortune, to die provisions of the Contractors License La (Chapter9
(commencing with Seco ]t%p) fDi 3 (the Busman andR f na caac)m APN Number. Occupancy •r�,
`Nat be a exempt Nclefi m and the bas for the alleged pt
axe t . Anr violation of / P y `J Pe
Section 70315 byanyppticaat fm a Femur subjects the applicant to a crvd pemhy of r / Q
pa mom then live hundred dollars (SSW). _ _
l, as awmr arthe prapeny.mmy emplayeea w;tn wages ae Nab eine nampenatiam, Required Inspections
will do Ne work, and the structure is not intended or oRerod for We (Sec. 7044, Business
end Pedfrwil..a Codw e: The Contractors License Ladocs na apply to an cram
or r of.,
'property who builds ai improves thereon, and who does such work himself or through
his own however,
Me provided Nat such improvements me on ter ed of
pRerW for
We l[ however, Ne building bur&6 or improvement sold within one yeabuild
on i wmple fon mh
owner builder will have Me bur0an of pronn8 Nat he did net bu Id mpmve for pea
pose o. own
co 1, , Me project of the property am exclusively cuoumdns wM 1 needonn cto . i l
ome La , desm,applIS.y
]044, owner
of and ny who builds
Code) The Contractus n
cense Law des root apply je ts owner of property who sedds r improver Gera and I!
who
enseLaw.
adsfm�uchpro3acmwith acontnnoKOliceased punuanuo Ne Comm�ctore -
r-I I wm Law -
❑LemexemplunderSec B&PCfm Nia mss -
Owner D ti- - s Yfs ,/g
WORKER'S COMPENSATION DECLARATION
thereby el maiundo-petultyof ocomoneofthefollow gWrlkeys Cu:
❑on. send will for
andra 37Wficate, of ComenrloCods:fc, the Workers Com n
.mime, r provided for by Satimn 3]00 of the Labor Code, fm the pertomuwe mine
workforwhich ill ii is issued. ,
Perm ..
i.
❑ I have erA will mainuiin Wahers Compensadon Immeme, m required M gadon, - -• ., _ "'
"' 3]OOof the labor Cade for Ne rfomunce mid work for which Nis it is lieu
'• 4 •
Pc P<
bfy Wor s Comp sal u a <mitt and Policy no UO V-
. Cerriec Policy No.: 4 -
CERTI�P ION FROM WORKERS'
COMPENSATION INSURANCE-
(This section wood ma be completedifNe permit is Forman h;'"dollars (5100)
no less.) ,
I certify Nat in the performance of Ne work for which this ammt iai.:ued, i shall - -
not employ any person N any manner so as to become subject to the Worker Compew-
action Laws of CaliEmd.. Data
Applicant -
NOTICE TO APPLICANT If, after i", this Certificate of Esmond., you should
become subject to Ne Workers Compensation pros ons of Ne Labor Cade, you must 2r ,
forthwith coal wit such provisions or this permit shall be domed revoked.
comply R pe r.,
CONSTRUCTION LENDING AGENCY '
.0 Q I hereby affirm that NereI. a emishuchon lending agency for the performance of 's '
Ne work for wh¢h Nis permit is named (Sea 30)7, Civ. C.)
Under. Name
..�: Lander. Addm.a
1 certify Me I have mad this application and sate that the above information is
0. -^z correct. I agree to comply with all city and worry milmances ad suite laws abdng to - ^ -
U O building construction, and hereby suthmriu representatives of this city in enter upon the , • - ,
.atm a toe tinned property for Inspection purposes - -
tL (W) agrce to save, indemnify and keep hamrless Ne City of Cuptttmo against „
.Q ;4 inimdeaj dgmf M. ati ft fpensev whtl meymany way accrue egunat aid City
,yi LTi, in consequence of Ne #metre# of this jjnnit.
S0. PP RCENTUNDE;STAyDSA IVILL COMPLY WITH ALL NON POINT "
S. 'lie /TSS '��U •,. . r" -
Signe A IicanJ Date
DOUS MATERIALS DISCLOSURE Q Will Me applicant or future holding nectipart store or handle haroardlous material Re-roofs
as defined by the Cupertino Municipal Code, Chapter 9.12, azul the HwIN and Safety Type of Roof "
Cade; Section 25532(x)] - r' _ a
❑yes 2+c6—
Will
NSw,, die,pP,;e,ntorfuturebuildingoc��par;tuse.gh;p K�,or,ey;res which All roofs shall be inspeeted`prior to any roofing material, being
emit air contamjn.msa.deflaedbyOnBay Area Air Quality Moragement .installed. If a roof is Installed without first obtaming'an inspection
°` `oYe. = I aggree, to remme.all,new materials for inspection. Applicant
�emi Iha2 ddtehassamFMM13wada
mnaMo- Chapter 6.95 afMnCali-' 'understands arid, will comply,with'all non point source regulations.
fame Health &'Safety Code, 25536. I uneerstand Net ifdiebaildmgdoesnacum�itlyyfvsmyrespomibdnytonm'd1yNeattupvit �fietOf—C:�i%V cuPencX`%�• Signature of'A
Dam ppltcant Date
Own�euN zed ogee, 1, ,a
- - - All roof coverings to be Class "B" or better
OFFICE