00030201 v
PERMIT NO. ^
;.CITY OF CUPERTINO-.
BUILDING DIVISION P-ER VIIT} CONTRACTOR IN C'ORMATIOIVa ao
—ITU—ILDINGADDRESS -" ". r - • '• SANI'fARYNO. APPLICATION SUBMITTAL DATE
// Amey*U., & /S �tq an; 'SP/vi(el 3 3� ,o�
' OWN tR'S NAME: �L• .�
G L, A / l /� I' OG�I(✓�I ���C N/C CONTROLM
ARCHITECT/ENGINEER
�o0 5/ rK i55cG -3/.9
LICENSED CONTRACTORS DECLARATIONSji t
oh hereby of ma that 1 son licensed Aer pmviuons of Chapter 9(comm ¢ Job Desenphon
r t.0 'w,Ih Sarson 9000)nfD,mwon3ofNe BusincnamdPmfaem Cade and DIY hceu I, "
full form and effect .4'
re0 w 4 Limns.Cie. - ` We# If
r
'd s. Dtm n
DECLARATION
+ e ,'! /jJ� ,
DECLARATION i• ;..�1,/�(/l•r� L 61N0•'�"/ D'"—r" /"�..r G'
y�37 und<ratendm lens shall as Pub' rcwNs { I-�
C• �'LL 4 feaRln i. k'
OWNER-BMDER' ECI.ARATION r '
Y I hertby R`m Inst I em exempt from the Contractors License Law for the
Otoll 6 hon 7031 5,Baanrcrc n d Profession.Cute.Any city arcounty
which req nes n'm ram oml alter. tato & -fish,or repmf any atm ire -
a_ Sq.Ft.Floor Area ' Valu tion.
tan' , t issuance,am rtgmrcs the applicantf win permit toicesatgned Chastatement r�, -
Net he is llmnsed pufswn,,o the pmvsmns of the Cannanore License Lew(Cheptn9 'I•', "• ` • " • O�
(communngwmth Serefan and
the
far alleged
m tlmi' scall of
Net he is exempt therefrom end du basis(or Ne alleged<xe pt .Any mild n of pPN:Numbe/r}/} ,Ccupancy Type
Section 7031.5 by any applicant fora perm,subjects the appy t to a civil penalty of ..H 'SAO / —03,�Va� .I 'i /< /
a more Nan rive hundred dollars(5500). - '. _ '
❑1,asowneroftheprapenymmyemployeeswithwageswe eirsolec=Wmatm. I ' £ 'wt..` .A'Requiredlnspectic -
and!Pr thewonk,and[heeie CimisnotmLidcdoioRef.dforssl apply to an Bmerin
and property
who
Cade.The Contractors License Law does ata apply m lf owner of _ f ` M �r,
•progeny who builds onmprovea.such i cid who does such-ntk himselfof through
his own employms•provitlW Nn such improvemm,a ere ret intended - Read for
ad Ifh verth.ve dil n'mpmvement Id Nino ey or
the
, r
0
wilt bu Id ill have th bathe fpm mg that h did i build improve`I tau "
paa1 f6ov ) - - , ^//
I caner f the property, nn' t g with licensed convec[nn to •tea,/) , r
numtNepJt(S 7004B se d professions Code)The Conarnre W * t r•^��
' cense law d«s nal apply t net of pr p.ny ho bollix , pro a thereo end ,,'Sv' r V - '
was se Law.for such prof u mecontn<,ry 11¢ensedp ants th Conveatofa 2,1 O
Littnu Law. / .
'slam exemp[antleiS ,B&P C for this rewom :rt, _ 4 � -i.
Owns -, Data ,•µ} �,l::. .
WORKERS COMPENSATION DECLARATION
• 1 h by ffi- de pe ratty of pe 1 fy m f the following dwlmtionl
❑Lha and will n t aCertificate ofC sent, self-inmre for Worket's Compm
cat n pr lied fur by Section 3900 of Ne Labor Code,for Ne pesfuimewe of th i 4''
work fmwmcM1 thi t"sed.' -
❑1 he m Wnrkefs Compensation Ineuruce u req fired by Sect on . r -1
17r111R1f`?1'
for .. a work for
wh'hth permit is issued
ntion naormea cI n and Pahcy number art:E ION FROM WORKERSOMPFNS ON INSURANCEss¢tin becompleted if NepemiilixforonehuMmddollen(SI00)tot • v , r
{ Icmifyth tin[he perfonnince of the workforwnchth apt lamasoed,I shall " v .I - ,
not employ any parson in my manner w as m became anbjecno the Wnrken'Compen- , ,` -
cationLawsofcahfnno nate -
APPlioent ^ no
.NOTICE TO APPLICANT:IL after making this Certificate of Exemption,You should
hecou¢subJart m the Workers Compenutian Provisions of the Labor Cade,you t
hwh m comply with such provisions or this pen,t shall be deemed rooked.
CONSTRUCTION LENDING AGENCY „ v f r r' n o " Y21
QI hereby Mum that them isa construction lending agency for the pernifmance of r3; ys,
the work for which this permit is issued(get 3097,Co,.C) 3
F „�•,
Tani Name.: s .
4•'C'i D Lenders Adder •. #• " .4 m
I certify that I have read this npplicni n end acne that the moa information
Q boned i agree w comply with all city and county ordinances and stem laws mining t
Obold g o traction,and hereby authonu representatives of this city to enter upon the •"s• r
above mentioned lumpeny'for inspection pmpaant
W Fy (We)agree to save,mdemnd'y and keep harmless the City of Cupertino against
Iiabdities,judgments,costs aid expenses which may my way accrue against said City i - ti ' Af t
�• W incrosequenceoflhegm^tingofthispemmic
APPLICANT IJBRSTANDS AND WILL COMPLY WITH A LNON-POINT' -
f..f SOI C' iULATIONS. 'A• t - a
Sib a ofAW)icud vector• 'Date .• r 't
Hgg RDOUSMATERIA DISCLOSURE -
Wiltthenppiw¢nl rfumriUuildingoe Pantstnremhaidlehaartlousmatedal Re-roofs
es darmid by the Cupem M n c ml'Cod hapten 9 12 nidi tin'lldib and Sefety
`eade sea anus3n,L' " ' i'. Type of Roof` -
4 El Yes L.
Will tin pplicmt future huildigmc put use equpmein or de res hien All,roofs`shall be inspected.prior to any roofing material being
emit henrdous air comers tits a.defmWb Be,Ame AnQuality Muag nt •installed 'If a roof is instal led'without trst obtaining an inspection"
District?'
I agree to 'remove all new materials for.ilispection. Applicant
(have reed thein dome materials regmreiwnteuMcr Chapter 695'of the Cali- 'un erste . s and will co ` ith all-"non'.point source regulations. ,
fame Health&Safety Cade.Sections 25505,25533 and 25534 1 mderstud that if the
building does not currently hive a tenant.Nu it is my malwnsibiliiymnaify @e occupant
of Ne iequircmema wed h moat be met pial to memance of a Cemlicate of Occupancy.
` nature III pplica +''' --"' ,Date
Owner or autnonre l each, .'} s;.' - Data -
'.Altroof coverin s to 6e Class•B"or better