00040101 CITY OF CUPERTINOPeMIT
RNo.
BUILDING DIVISION - 'PERMIT CONTRACTOR INFORMATION:
HUHMINGADDRESS:
SANITARY NO. APP[LIICATION SUBMITfAL DATE
/0119 S-44KIRtj IA
OWNfi 'S NAh /�y3 II pp�-�,�-/
-1 NIC CONTROL
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LICENSEDCOMRACIOR'SDECLARATION
Z= 1 hereby alfrm Nat 1 am licensed uMcr pmviuons of Clupur 9(co.mg Job DCS r II n - -
I-_L� withSmbn70(p)ofDivision3 afthc Business and RpofwioinCmq..ne myueemaia S�'4�e>-tem 4puq-�•�g,,t a J CI. ��\
�a< in full farce tad effect. l.C�✓LIA n� -/Z t . . aaattt r� IJ
Lianas Clw Wc.x rP VJ GC ( /gam•!., �Q
3 F .Dem Conuacmr A/C
a O g ll the
DECLARATION 1
1 understand my plans shall us .s public maids •-
_^c OWNER-BUILDER DECLARATION'
t-z>' 1 hereby'Flinn the,I em eaempl from Ne Commutes Liceme Law,for the ?
f Z 0 foll.mg,eason.(Smian 703 I.S.Business and Pmfmsions Cade:Any city or mduty -a
iC which regYirts a permit m comWn,slur,Improve,dcmoRsh,m r ser say sWcwC
a_ Sq. Ft. Floor Area Valuation
Prior to its ismana,data requires the applicant for such permit m file asigned statement
Net he is licensed pam usnt ro Ne movisiom,of We ConvactMs Licenm uo(Chelgu9 -
(commencing with Section 7000)ofDivision 3 of the Business and Profeasinm Code)or ccu ane ppN Number 'n' ' OT '
„ IN,he is caempt doorman end the b nus for the alleged ea<mptlan,Any venation a ^7 - _ - P Y Type
Section 7031.5 by say apple.,for s permit subjects the apparent to a civil pemhy of
more than rive hundred dollars(5500), •�•/"�
p( Q Las owner ofine property,m my employees with wages es chair sale compensation, Required Inspections ..
dothllkall ode: structure istotimeMed,UW
hot a(Sec.oan ownar of
t and Professions Code:The oyes theme Lir<ns<Iww does trot ds hi to if owner though
.a progeny who builds or improves Merton,thd who dors such wok dad].ci tluough {.
his own employed,provided Nil such i improvement
is old a thin not inuMed m, k,m.'tW ..
ffiand for
We.If,howeveg ll hsv Wilding bur len of moving
is an la,within We Wild r improve
lefon,ths '
ownenbuilder will hive the burden of ptaving that he did nm Wild m improve for pus-
• .pose of We.).
❑I.as owner of the mop<M,am<sclusively convecting with licensed canvsmm to .. 7/
concoct the project(Sat.TMC,Business ami Profession Code:)The Candoctor's Li. 7/ ,
cense law does not apply to so owner of pmpeny who builds m impravd,h rma.and Q r
who contracts for such pmjecu with ac mr(O ls,anaed pursuant to the Cantncmes•
Licenw Law. ` .
tinder Ser. Bk P C for thisiw '
ODu
WORKER'S COMPENSATION DECLARATION t J.
1 hereby arm undo,penally of prrjury We of taw following daclandiam: I
J I have and will mintier a Cenifcau ofconsenuo self-insure fm Workees camper.
anion,as provided for by Section 3700 of Ne Labor Code,fm the performance of,he _
fm which this pcmut is iasuod. _ "
have and will maimda Wortsls Compenotion Nommee,m re bond by Section T�1-
ofthelabar Cada,for perfo.e ci One wont far which this permit u issued.
MY WorkCemer. OMPENATIONAN fI�(COMPENSATIONINSURANCE '- 00 U(7T Ii nncednot becomple,etlJthepemtiliv farone huMrW dollar 15100)orlea) '
nm employ any person iia any manor so m to hcmme subj&c to the Waheri Compen-
mtionLawsofCdnfomia.Dam y +
Applicant _ m
NOTICE TO APPLICANT:If,afar making this C<nifi<ate of Eaemption,you should
amore subj.t ro Ne Workcls Compensation provisions of the labor Code,you must
fmthwi,h comply with wch provision"is permit shall b<dcemed rooked.
CONMUC ION LENDING AGENCY
0 Q I Jimmy safrm Wt Nem is a concoction lending agency fa the perfurmence of '
l the..,it for which this permit is issued(Sec.3097,Civ.C.)
'vF Lender's Name
(yes > Unaim.Addrc.ss:
W A I c nify Ni I have reed thu apphcatiW and stats Nat the above information I.
ca 1 I Moe to comply with all city and county mdimmem anal.can laws relating to „
Z budding connottoction.and Wmbyauthonu representatives ofthiscty to enter upon the
f..) C abovnm<n,ioned property for inspeetion puryaaes. - - -
W F.. (We)agree m save.Indemnify and keep humless tae City of Cupenlno Murat
Q,V liabilities,judgmemacduandeaPenmgw¢h may inany way mc against Laid City - -
�. W in conoquence of the gronting of this t t ,
[. � PP�WER-ANl W ,C061PLY WITN ALL NOY-IgIN'Dti
H I g—
SiSignatureof ApplicaARDow
HAZARDOUS
( r
HAZARDODO US MATERIALS DISCLOSURE t
Will dm applicant or future Wilding occupant smrtmhandle hazardous maurielRep
m defined by the Cupertino Municipal Cade.Chapter 9.13,and the Health aSefe,y Type.ofs
t
-
Code,s�tmnzss3z(,n nti� e,of'Roof _ ,y
❑Yes
Will be applicant of future brilding mcupent use equipment or devices which Allroofs shall be inspected prior to an roofing material being'
f 3iava'wdooxaI,mmumirunuaidefnWbydoB.,Area AnQualltyManagement installed. If a roof is ins lled Without first obtaining an inspection
❑Yes I agree to remov all Lpy
ials for inspection. Applicant
m, sIbavamadthchazmdousms 'nlsnz�,
unhrChapter695ofN<Cui. Understands•and 1 ith all rion point source regulations.
tomo Neelth de Safny Cod on 5 25534.I uneentand case ifacuvendyh sae tem t, onsibility w notify themal metfeCertificme of Occuparcy. , o ,
- r Signature of Applidant ; ) „ - Date
er m ea mixed ag r, a Date L
'All roof coverings to be Class`B"or better
• , OFFICE
CITY OF CUPERTINO PtdLzYi£.i '+'ST3ri+' at'c€:T; lyy`t�it : .s.a/tita��ttt 7` x�z PERMIT NO.
BUILDING DIVISION ,`� P�i Rr ^, ^ VNT1, ;101C}ll\CjR �L �' pllOa� �e�'•
BUILDING ADDRESS tZ
a sSRS.
D.\ 1.1..1 f^. -a I�^U SANITARYNO APPLICATION SUBMITTAL DAT
J' 1
OWNER'S NAM6`: y!! t ( ?,., 1t,3..rv, N/C CONTROL#
r.: i.^ .rr -Y+ i^�' r .'v1 � ,•ii111%1 ._ i,
HONE:
t
r
ARCHITECT/ENGINEER
/ -/ 1, :;:-Y tii. IS d ,.5ULDING"PERWEI
u
y<„ NOTES
Z=c t I lob Description
s
foo
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Sq. Ft. Floor Area Valuation.
APN Number ,/)1 Occupancy Type
Required Inspections
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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 ue materials for inspection. Applicant
understands and wi 1 oiply with all non point source regulations.
Signature of Applicant Date
All roof coverings to be Class"B"or better
APPLICANT'S POSTING COPY