00040106 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION - PERMIT• CONTRACTOR INFORMATION: 00OL40 /0 &
,a I ' 4R.f � '0. ` N SANITARY NO. API'I.ICATIONSIIBMITfAL DATE
k1 %0 k3% f10_ae•/_IL"eC n
O N611 NAM �Wk \\ CQa k r N/C C°NTROa LN J
,
IONI:, -)V S/Vt .�rCii.. 4a •1 III �.�.��'�/`V� � • ; , •.. .
ARCIIITECI'/ENGIN.ER I C w 6 ya3�y sHULDINO PERMIT INFO
�00 1 IU �
' aUti
i .LICENSED CONTRACTOR'S DECLARATION w l -
O z=- I hereby amrm th.t I am licenw uMer provisions of Chapter 9(cmnneanoing , Job Description .
s 'wM Sauon TOJO)ofD n3 of the Business a//nd Pr.faamn Code,aMmylicese
�Z,4
in ome and eRecl
u,¢� Lnanu Clash2-4-
c,
3't g Date1�'��lRCHI=S ECL
u.O ARCHITECTS Ds public
ON L.a yy
5 n<O 1 undersMO my plans aM1dl a used u Public rcwrda /C/��jA�(�f �t ///�
un a.�,�e licensed Profuaionul / a�`s�\ JT/— `� . -yA/R \' -
OWNER-BUILDER DECLARATION
f-Z< I hereby amen Thu 1 an naempt from the Cmaratoh License law for the
ac ac G following region.(Sation 1031.5.Business W Professions Code:Any city or county
ou 2 watch rop iree a formal to comwcl,alter,improve,demalish,or"pair my surname:
prior to it.ism.xq dao tequircs,b,it"Imint fortiethperm,to mea sienedrlatemmr Sq. f't. Floor Area /Y Valuation
IN theislicensedpumuanuotheprovisionsofthe Conr tars Ucrosehw(C ptu9 - r L 410
(c l he is exempt therefrom
and the basis for of aHeged exeudon.Anyons Code)or ApN Number 'Occu ane T e
tht be is 31.5 b say ppli and the.para for the cis din exemption.Any viuleuon of ,n P Yt YP
Section 103 LS by any app.cmt far a permiuubjas the applicmuo a civil perety of
not more then five hundred dollars(53001.
❑1.aeownerOr,nepmpeny,armyemplaygeawitnwagea..ndr.alacampe...has, • Required Inspections
will do Ne work and thc.arteld a is era imrnded oroRaed for We(Sao.1044.Bounce;
and Professions Code:The Convactoi s License Law does not apply to an owner of
progeny who Wilda or improves thcrcon.and who does such work himself in derough -
his awn employees,provided has such impavemmu art no,intended ce uRared for - '•
pale.If,however,the Wilding or improvement is sold within one year of ooWlecon,the
owner-Wilder will arc to Wrden of proving that he did me Wild or improve for parr-
poseofaale.).
I,in owner of due prosenN am exclusively commdng with licensed contractors to 1 - -
construct she project(Sec.704,1,Bmina.and Professions Code:)The Contractor Li- - •��t
cease Law don.not apply 1.m owner of property who build,m improver throe and
a . '
whucontrts for such projas with a contruc,00e licensed pursuant tura Contractors
License Law.
itemptu .B�P�far Nis • //J���,�f�IL`
A_ Get
WORCOMPENeA O ECIARxnON rO'N�• "`a�D
KER'S
L hereby am.under perry of pe Jury one of the following declaration: �k�
]l have and will maintain a CesiOcas ofcansenua self-insure for Workers Compen- - - JUL (] �]2M
,i s provided for by Section 37W of to Labor Code,for the performance of the -01O
fro wh ch dm perms is ismcd +...��
M1 M will mainwn Workers compensation Insurance me"ored by.Section - ..�•_ -
1 p fatrqi
e bo Code,far the performentt of the wart far rode Wh«permit idiaeued. I� '; 1 w 7'"' - '•��'�Dlpg/�
My Wurk Compensation surmm carom and Poll,a / —BUILDING -
Camer. Pol cy No _B U•, s - � ry' a
E He OF EXEMPTION FROMAklK RS
' COMPENSATION INSURANCE - APR; -I L rs000 }/�I
('This aadmnaWom
dma cpleted ifthe Psion u for.hardreddallera(SI00) APRa I ,
I certify thein the pertormence of to work forwatch NiapcmJ,is issued,i shill
Wil employ any porton in any manna so.,m become subject m the Workers'Compen-. D -
setianlswaafCdificnimDue
Applicant -
NOTICE TO APPLICANT.If,after making his Certificate of Exemption,you should `�""w��....,,,,4,.•,wl -
become subject to the Workers Cm amatum previsions of the Labor Code,you mus,
- 'forthwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY:
O.Q IAercbY affirmNuramisaconstm donleMingagencyfanheperfort of - r
the wart rot which thin permit is issued(Sit.3091.civ.C.)
Leader,Name
Fy > Larder.Address
QI unify the 1 have trial thea apphotaim and awe that the above information is -
...I.l agme to comply with dl city arta county ordinances and stain laws entering to
.z buildingconedpro,mdhertbyeutbonurposes wive«of,hiwiry to enter upon Ne „ a ,
ubove-me e) go Property for inspection keep ha: "
LL (We)e8ra m cave,Indemnify and kap harmieas the City of Cupcnino against -
O 67Lc
dili,ie.,,jutlgmenis.costs apt eapenwaa�hi may in my wayaccrueagaimt said City
�s L17onmqence of Negmntin8 thisp�t P TUNDERSfANDSa U`'Iyr�1 OMPLY WITH ALL NON-ItlINT
0 RCE RIi TION /`n ,•�]
A.
Sigmtoreof ApplicanJComfictor Due v - `� ! O f J O
' HATARDOUSMATERIAIS DISCLOSURE •
Will the applicant or futurt building acupmumrc or handle aeardous mmeod Re-roofs • -
u defined by the Cupertino Municipal Code,Chapter9.12,and the linet.ad Safely
.cad Section 255320)1
❑Y ^i Type of Roof
.:r 1a" r
W'll the. treat or future Wilding oacupent use equipment rde'ees which "All roofs shall be inspected prior to any roofing,materi al being.
emit hwd us an conumnw,s.,de0ned by the Bay Are.A Quality Management installed. If a roof is Installed without first obtaining an inspection -
Dis"let, ,�,� .'I,.a reeIto remove all n w materials for inspection. Applicant :
❑Y<s o
a Ihuerodthehawdousmiten sL5533-md255M.]
mderChapsrfi93ofthcCdi un erstands an it c reply with all non point source regulations.
forma Nu afatYCode,Sec' s 2 urdeesndthaAngdoesma'a ly haveem rat, apomibilirymmrify the aeupm, ',JA
�`/�.1 �of ere,domems un me ofa Cmigcem of - y. V
'cz
Signature of Applicant ! -- -Date
nmwZr or.uthoJaed agent .°ate. b
All roof coverings to be Class"B"of better
OFFICE
CITY OF CUPERTINO s �r *fit n'�yi�t#�v+r�ry�f` Jt t '•'^'':I {`?tt ';''utt # PERMIT NO.
BUILDING DIVISION PERP *,1.:01\ .I�t1C OW
.:� a,{,'--LK i'*f'�1t +:S "#2UYS,dt3b Ix?+.'eM'S eti+II; aTxx3r.Ws �/r
BUILDING ADDRESS:
'y�y.,,/ i�( ,t,,,{ ',,'rr .�J :S, •S'n"'t '/«L,1 q,�'"1 \.V SANITARY NO. APPLICATION SUBMITTAL DAT
NIC CONTROL#
El
ARCHITECT/ENGINEER ° q :`x�h+^�•i,S6i1EDINDPCRMrI'INFO`
.00 oo
F=� NOTES
NFc Job Description
�w 'NCO tK)ScJC-
Sll�
° 4l l.. ,;i'•,�::°� 1 l_.,�r.f �,q . "' f'�,sr'+'' '—C�ll:� ��:.i �. �L,
1 _U rvi�
pati ,AvA'
3 m Sq. Ft. Floor Area Valuation
APN Number (krupkncy Type
7'
Required Insp ctions
oci
Y >
xa
z
UO
OF#
U
r
U z Z
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 ,
understands and will c ply with all non point source regulations.
`Signature of Applicant Date
All roof coverings to be Class"B"or better
APPLICANT'S POSTING COPY