00030213(• CITY OF•CUPERTINO ., ?
BUILDING DIVISION PERMIT , CONTRACTOR INFORMATION: PERMIT No.
0Dc03 I'J
Z BUILDING ADDRESS:
9 RI .n kir /� 1 V7,�20.11t�'tlap V�`Q�— I o- L4• C—G' I- SANITARY NO. APPLICATION SIIB/fM�fITALDATE
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1 - — BALDING PERMIT INFO
• 51AAMz ASOC1 S -4t0`3 _377' .. t
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Z LICENSED CONTRACTOR'S DECLARATION r
I hent BLm mal I un Bamad oder Job If
• ..If
O Z o Y e provision.of Cheerer 9(cam,nroing `
� p_C'w withsation]000)ofDiJisi.n 3'.fthe Buainas/ad Rgofasiom Code. my license.
:yx" in full•facead cRai.
G Lie g /N�ioae iPE7lb✓fN76A) . � l+�A-51�/�eYi� u,v/r
5 u.F' Dan=nn ^ Corivac g /J��r� /j� �/� ,ate �/t/� ',I Al'
g
g O ARCHI'1'ECrS DECLARATION -. /�F/�D� 1 Y-f A./D GYgg71C�O/eCS� /red/ W 4eL Al'
E indeatud my plans,IWi ba used a while rccads 'V 8G 4A
RIM
'Listened Professional v .
u� _ OWNER-BUMDER DECLARATION •' '"
C Z< 1 hereby affirm that I sin exempt fund the Comraaol.License Law for the
❑ follo si g memo(Section M1.5,Business ad Profession.Curb Any city or county
whi M1¢qulma a w it an cnvwa,elle,improve,demoh,h,or repair my suuclure S Ft. Floor Area
pri�rm t i.auana.also R9utres daft linm(.much pert m rile a signed sorter q. J� V31B8tlOn '
thatheiehmnxdpunuam m me provisions ofine ConvanNs License Law(C Pbuc) - QI{ �//yr/11r//a .
(commencing with Section]000)of Division 3 of the Bisiroaa and Professions Codc)us
that he is aempt thcmfmm and the basis forme alleged exemption,Any yiomnon of PN Number .,occupancy
,ccupancy Type
Section 7031.5 by my applicant for a pentit subjects the apph mt to a civil penally of
'p of more them five hundred dollars(t300).
ta,.wner.f the prowny.amy employ..with wage,as their mleaom"amon, Required Inspections
'will dome vamk,and thc,Ruclme i,nm intended urohrm,for stle(Sec:]Oda,Business
and RofaCode:qhs C mra law docs a ply us an
owner
Iwho build,or vieer thieo,and who dao ouch work himselfothrough
hi,o"employee,Provided that such improements rt oro d III,offered for
redaIf,however the holding a;improememhnld within one yearofoopetion,
i
-
be
wus of e.) will have Uie Baden of proving mal he did not W ild a improve far Pur- //
pose ousels.).
Q I, .war of the property,un exclusively ron.uting with licenaod cnaactoia m I
consumer the project(Sec.9oga,Buainai d Pmfealom Cede:)'Ihe Convacmre Lt.
c an law dao not apply to owner pr say who builds a impova mmmil.and
who contracts for such pajats able. tort.)lkemed promart to the Ca.badmle - +
License Law. "
77i�
tB k P C for this maim,
Dae D o •R SCOMPENS NDECLARATION
n by Safion 3700 of be tabor Cade,for the wrforrrwue of the
for which this permit is issued. -
w 'I h end ill mains n Wnfkera Compensation Insurance as required by Section -
3] frac I Code.fa be pefformvre of the wort forwh h this pmt i s ismd -
Crrier m n.uoily nese Cpgq,pPlQynu
CERTIFICATE OF EXEMPTION FROM WORKPI191
COMPENSATION INSURANCEor less.)
(This section and nes W completed ifbe panni,ie(.r one hundred donee Pt 100) .
I reify thetin the peiformmaaf the we,k for which his permit is named.I shall
not employ my were.in any manner an as to become subject o$e Wohers'Compre. -
sation laws of califomia.Dan r
Applicant -
NOTICE TO APPLICANT:if,-tier making this Centeno of Exemption.You should - + •?. -1 -
become subject to be Workers Compensation provisions of the Ld or Code,you n
mi
forthwith comply with such Provisions or this permit mail be daeuid revokes], -
CONSTRUCTION LENDING AGENCY
O.O I hereby abmn that mem is a constmeden performance agency for the perforrnce of
me wor
'� k for which bis pm.il is iamd(Sen.3091,Civ.C.) -
r�r Lenders Name
C4
F>•r Ianaer,Addrtan
G 1 unify then 1 have read this application aid ante Net the above informed..is
correct.I agna m comply with all city and n rmy ordinances and suite laws reining to
U O .building conawcdon and hereby audience iepn¢nutivea of his city to w
erre,on the
tlbrwe-m ariand prow.,ter inepestma par,aa,
1 We)-gra m save,indemnify and kap hamleaa the City of Cupertino egauut -
O V liabili40,jdgmenn,tours and ex nse,which only inns wet license,an.seta City
-
income via of '
},� 9 e me gmn.g o this permit.
F+. APPLICANT UNDERST 5 IND WILL COMPLY WI,'H ALI.rNON-POINT
Si'mome M APo,camUrnmicus, Data r - -
HAZARDOUSMATERIALSDISCLOSURE
Will the applicant or forms building receptor store of hadle haabou,minimal Re-roofs
an dcfiad by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety' -
Code.Salion8532(tl)? • d: Type of Roof
❑Yes a ,
Will the applicant or faareIWildiIS occupant use egaipmemIt devinswhich All roofs shall be inspected prior to any roofing material being
.m it hiadoua air coaimi,mnts as defined by the Bay Ana AG Quality Mmegcment installed. If a roof is installed without first obtaining an inspection
5i.trKt] .
❑Yea Ne ,. - I a ree to remove a 1 new materials for inspection. Applicant
• IhavcradthehewduuamsnnalaRyuiremen.uderChapnr6.93oftheCali U ands d'wi comply with all non point source regulations: '
forma Health&Safety Code.Si: ,2Ss33 end 2553..1 undsomm l ^
Iwildin
currently have an t, it is mYrapm.ibibrilai nifytheaapar
e ieyuirtmemn h''h r vet p le iuuena of a Certinnte of Occup y. J
t' ow rat Signature of Applicant Date
'd lig t Dare •
All roof coverings to be'Class"B••or better
OFFICE