00020187CITY OF CUPERTINO .'
CONTRACTOR INFORMATION:
- PERMIT NO:
BUILDING DIVISION -PERMIT
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BUILDING ADDRESS: -
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- SANITARY NO.-
APPLICATION SUBMITTAL DATE
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\RCHI'TECT/HNGINEER + -
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I1tlLDINO P1iRMIT INTO
LICENSED CONTRACTOR'S DECLARATION
' I Wombs, aR That I w licensed under Provisions of Chapter 9 (commencing
• - Job Description r
with lifoom]0l'Irm,ivii n3afdreBwinds and P�ofeu�ionar C«le,Wmy license is
in lull force sad eRal.
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Cleanse Clau
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Onc - G.o DELL
ARCHITECTS DECLARATION.
1 unddrswd shall deuced
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my plans u public remrdx
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Licensed professional -
-BUILDER DECLARON
'OWNER ATI
1 et 1 sm eaempl from the Conuator's License Lew fse the7
hereby, affirm N
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following town. (Section 7031.5. Business and Prefesdoni Cade: Any city or county
Sq. Ft. Floor Area
Valuation
which mgara a Permit m cons°""• alter, improve, doessish' m iepalr my,m,cture
h permit to fil...ignmrment
prim to its iuuna,alwre arms the opplicam fon«W
CBu LifmivAsC erg
Nnhe ncinmedpurcosmid N)Pmvisiiim3
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ava
(mmhe exgwithS f mu Cadelm
on,
�Ay PN Numb r
PN
Occupancy Type "
and th basisoa3
is alleged excoriation. liPenaor of
is li atW dm bpi, (w allegedAnydvi
Ilul therefrom
Iany
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P Y YP
ube
o by any applicant a civil
31.5 b sip permit objects the applianl to a civil pcwry of
,
am sone drum s (a
pm more Nen five hundred tlnRan (5300).
Laa nwnar rrthe ptoperr•wmr empmyaa wim.:g«dnairame gnmpen,aian.
,
.. - Required Inspections
will da Ne work, mad themucturb is no imendNoroReted forsam(Sri.]0'M, Business
�0hd
Profeuions Coda: The Conlrietor'a License Law does not apply 1. an owner of
Miami who builds or mr mvu thereon, and who does such work himself or through
his own employed, Provided that such improvements art not inteedatl ce offered fw
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aide. If. bowever, rhe building or improvement is sold within one yearofcompleuoo,the
caner -builder will have the burden of proving that he did not build w improve for per-
pose of ole.).'.
❑ 1.su u of ma property, am escluai conVam ems with to
r do, send ) The Ccunuanms
come La the proiat (Sec. ]IH#, Bituowner of aM Profauom Cade:) Treves common.
Taw doe, r01 apply je an.wna of property who Wills or Improves and
end
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Comon.
whenseLaetsf«such prolate with eronoac,«(q li«need pursont to the Conlnctala
License law.
❑ I ameaemptunder sm. - .B&P C for this mmon
Owner • , . ' n : Date
WORKER'S COMPENSATION DECLARATION
�I hereby affirm under penally of perjury We of the following daclanllom:
1
�J�r1move and will maintain a Certificate of Consent to sel6insum forworkefs Camper.
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kprovided iso Sectionm3]00 of the Labor Cade: fm me pirtonona of me
,
work mss
wom
forwhich #amid is issued.
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have C requited by Section
E]I love and will maintain Pockets Compensation
Oo ar Cale, urn the work for which mss #[oil is issued.mY
Worm 1, C. turn1e camq and Policy no
Cartier:S COf I wWo'icy No.:
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CERTIFlCATE OF EXEMPTION FROM WORKERS'
,-
COMPENSATIONINSURANCE'
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(Thisseelinn need nm bec.mPleled iftheprnnil is f.ronehutdmddollm(3100)
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I cmify that in the pertorowasm.f the work for which mss permit is issued, I shell
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not employ any person in any man....... m be«nue eubiat some Waken' Cons'n-
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actionlawsofCalifomia.Dam
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Applicant
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NOTICE TO APPLICANT, If, aha making this Certificate of Exemption, you should
trcome subject to the Workels Compensation provisions of the Labor Code. you must
forthwith comply with such Provisions or this permit shall ba domsed revoked.
CONSTRUCTION LENDING AGENCY
,
I hereby of firm that mem is a manumcuon lending agency forthe performance of
-the work for which this Fermat is issued (Sm. 3097, Ci¢ Q
Landale Name
.
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fardels Address -
' I certify mot I have mer this application and state th01 the aW4 information Is
connect. I agree to comply with all city and county Ordinances ad ole laws missing 10
Wildingcontiousion, OndherebymlhOr.mprrmntatlwea ofmus,i,y. [mer.pm Qm
mbov.-ommianed property for inspection purposes.
(We) sigma,. save, mdamnify and kap halmlaw the City of Cupertino al
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habditie,,judgments. rods Ondeapmee, which may in anywry scers,,iti st said City
in eomagaac of the granting of this permil.
APPLICANT UNDERbTA DS VD WILL COMPLY WITH ALI.�NONN--POI,N'r
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SOURCIiREGUyl
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Si�re�o�ff AAppelf�-UC.m.tae - � I Dam
- - HAZARDOUS MATERIALS DISCLOSURE
' Willda."Imemm future building occupant ,in. or handle lumadhm material'
Re -roofs 0' -
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u defined by the Cupertino Municipal Cuda Chapter 9.12, and the Health and Safety,-"
Code, Section 25532(.)? ', / s -
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Typo, of Roof ,.
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All roofs shall be inspected,prior to any y roofing, material being
Will ft applicant sir future building mcupml use equimem por devices which
crit historians au sumsoimnls Bs defined by the Bay Area Ab Quality Management
installedd . If a roof is installed withouff-first obtaining an inspection
°'`r'"' ��
❑Yes '
I agree, to remove -all new materials for inspection. Applicant
un erstands n 1 comply with all non point source regulations. .
have read a,d«.m tectal, mgdom n� orderL ase d95 of ft Gall-
fomu Health & Safely Code m 25505.2533 and 25530.1 andsomaral thin if the
buddrageasn«cu tY mol, remit is my maponslbirym ratify thea.,not
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of the rtyw et ptiIX lu nnuence of a Ceri Tc I�_ {jtY<u My
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Sig re of ApplicantDate irl
_ .. .• ;. Applicant!,.
.Own edagent• ate -
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. All roof coverings to be Class "B" or better
OFFICE
o� M � 0 T �
FEB 2 8 2000
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APPROVED I
APPROVED
IN ACCORDANCE WITH THE CITY OF.
CUPERTINO CODES AND ORDINANCES
!)ATE
SIGNED
This set of pwr is and -spcciiications MUST
be kept on Via jot at cll times and it is un
lawful to ma',o .ny d anges or alterations
on same wait,.u'. ,v:,i1 n permission from
the buiwmg Dopi., Cay of Cupertino.
/ The stamp.ng of this p 7 and specifications
>HALL NOT be he d to pe.mit or to be alt
ipproval of the violation of any provisi0ne
env City O;dmance or State Lft
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III FEB 2 B 2000
7 Sd�y'