00040105 CITY OF CUPERTINO'. ,'. :-'r , - PERMITNO. .r
,.,BUILDING DIVISION PERMI CONTRACTORMORMATIONr � )O-VOIQ5
RUILDING ADDRESS:- ,. ,�^{ ��3\�ar � 1�l\,/^�
- tlk./0. �� 1\SJ�L.. QV\ '' SANITARYNO. APPLICL DATE
ATION SUBMITTA
IN S: 1(3�wtleu u>:, ►s 73Nevext let ti,, , .,
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C]11}3AnTV+A e ,pb �'1 Rr Qa-\w N❑, ,., CONTROL#
Jj q yy/ I /Oy 1 14 .
i.V C l _1S PERMIT'IN
-ARCHITECT/ENGINEER ^/rh"iea/ IJJ[ .
Co 9'1032 4' ,
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' LICENSEDCONTRAcCrnORS DECLARATI'O
N',
o: I hereby afrm that I em licensed ablerO provisions of Chapter
9(commenting
1n n
J'•o/bf�D�4efitsc)O'ro1in pt&Yion
mWmmdrofesssomCad andmylicaans
ifullforceenec
Dcomn tiow ,a
1
l.t.
ARCHITECTS DECLCDECLARA
C O TION
f�p, l andemaid my pl hell be uud as P bl'c rends - + w/1 a I („L/l'f
i a 0 0 `Lkenmd lPohnsimel
OWNER-BUILDER DECLARATION.rs' k�' ' v_ i •s' < .
1 hereby soros that 1 sin exempt from the Contractor License LIss for the
E Z D following (Sats 7031 5 Business and Professions Code Any Iry arc u ry
da when ropures a Permit ro countruct,they, p a< ban:or expam anyaw rmeS F[ Floor Area Valuation'
prix tor n ,atmos resdae appy anti m
suchpcath flmsgned auteme t q' f
(her M1
r
(tormenting se'dNpirosm unaNoofDivisican
3
Ceemmmai aLMProfessions 1CeChdader)a9
lOcp,hit he' ezenml Nertlrom and!N basis forNe alleged exemption. izy violative oAPN Number, ane Tye
Seroo 703I5by yaipficmrfmapmtsubjmtsNeepliC=1104CiVilmryof G3+ ,UO
not more Nan Eve hundred dollen(3300). 1-
❑I,mowner of Neprogeny,or my employees'wish wages as thainalo compeneatia, Required Inspections•
will do the work aidN w
scwret m ot' dcd Reredf al (Seo 7044Homes, H
and Prof m Code:The Contractors Cumin Law does out apply to an'owne,of
his who builds or' Pro Na and h d h oh h If its er) •Y n .. -.
his o n e Ployees Provided Nat h'mprov U are am imeracked-or offered for
s r i 4"
-vie.if,hone the am Id g improvement Id Nin on y -f e mplUm Ne „ s
ownerWilder mod[have the burden of Prov g that he did ml build .prove fm Pur `'!. tL�'(}�11 /JJ _n
you of sale.). .. - 9700`06/x'4 LE `
El I v owner of the property,sin exclusively con owfine wish licensed c autrmtl=t0
camwct the ro eel .70,W H s d professions
p3
(Sec a mess en Profs ns Code. The Li-
cert onor tinea no apply to m own of openy who builds or impto the
Nercon,aid" - l U l'. O . . Q
v.
. . . a J
who o wcr for such projecu wW o dor(s)liceneed pursuant to rhe Conwcrors - J. '
W<enae Lass.
exempts ec. B&PCfaNiawn BUILDING '
'OGet.M.
.. (r
WORKER'S COMPENSATION DECLARATION -
c '1 hereby affrm under penalty of Perjury one of dm following decla.ithoW '
I have and will winrain a Cenifmase of Commit to self-insure for Worker a Compen-
esion'm Provided for by Section 3700 of On Labor Code forms performma of the s, "f_-
k for whmh d, perms is ssued - 2.
IJ�1
have d II mammon Wonkcn Compensation Inmrmrte required by.Section
g7Qn of dm ba Crile,fo Ne perforrmnceofthe work forwh htla permr,siaa ed - •�•.-+..
My W C 'Fr
eco b omnes tamer and Policy
♦
Center •�--a- —PoIicY No _ f5 Lt .�J i
L - CERTIFlCATEOFP.KEMPTIONFR WORKERS
H COMPENSATION INSURANCE y
Th
nn10)
orlea, .`APR, 0LL
-
1 serfily that in Neperfowsrme of Ne work forwhich this permit s issued,i shall
not employ any person in any mmmr am as to become sulnect to the Workers'Compen-. -
sati Laws of Califome Dae - - - - ' '' :. I ••
,APPlcanr t By
NOTICE TO APPLICANT:If,after m
r making this Ceficate of Exemption,you should o ----�_T_ -
become subjectto the Woikefs Compensation provisions of the Labor Cade,you must
forthwith comply with such provisions m Nis pewit shell he deemed revoked.
z �, CONSTRUCTION LENDING AGENCY
Ise bysffwthuNs=is asonstruction I Mmg aging for he perfosmme f %' a
Z)ra s'
the work for which this perms is issued(Sec-7097,Civ.C.)E., Name..--
i lenders Name _ 1 ". r, i .
,
W 0 s i Certify Nm Throntrimithispylic 1 d ua c er the bo f rout s
�+ building
1ogre to comply with all 'rydi o nd ensue d mr I rupon t '• t s ry° - -' ,
r� rZ i build' gconstruction. dM1 by a urepresentatives ofrm " r-r apo Na "-t.
V abo a ! progeny f specuon'puse an ^
W t~ - (W) 8 m s indemnify and P l a inn the Cay f C pen no a8 mit
nKnli.C09160 d n 9 ICh may
y f,) liabilifesjudg may
way crve against said City �'
o grant
'n:OW" lotonsequence of NERSTAN1.oANilI W1 .COM PLYWITHAILNON-POINT , - - r
9 URCB REGDI TIf ._T
Signature mAPPlica oCommcror `
„HAZARDOUS MATERIALS DISCLOSURE'
' - Will NeepplicenrorfuwreWildingoccupmummortimdlensaardousmaand R6-roofs
is defined by,the Cupertino MunicipalCode.Chapter 9.12,and Ne Health and Safety -
Code,Sormn 25533(o) .Type"of,Roof .. , .
ElY - }1
'
Will the apphcmi fr bmidingocc p, tuseequp , rdevices whnh All roofs shall be inspected prior to anyylroofing material being
emir hand air comminns defined by the Bay Am Air Quality Management installed. If.a roof is,mstalled without first obtaining an'inspeetion
0 I agree to remove'al new materials for inspection: Applicant
Dyes �TNo� � d
Iha nnul n urar rmrerlaisV..N.notorCh pre 695 rtheGeli , un erstands it comply with all non point source regulatlomi.
fvinu H nIN&safe Cade S n 2 5d25534 I nnMsundIM1 r fqbnine dYh t t ponsbltyt osfyth orcupmt i. "` s �' 6V
4.- 1=
f N rryof a Cmffi m_q( copnycy,
/` I '+'ILLJ ,Signature�ofAppLcan[ Date
Ow raulho-M .1-d al< a ^ r 'n
'All roof covering's to be Class`Br'or better
OFFICEt
CITY OF CUPERTINO tt aF{$T$E. - ph�i15?fi#:'[l0A �MIW,I1#i�5��a�$�'�,+$' '�.fow PERMIT NO.
BUILDING DIVISION ^PERP ` " v4,ONTRACTORi :ORI " ON.�
- "t reoa t a s . :, ar � . mx G �<j
BUILDING ADDRESS: "
SANITARY NO. APPLI ATIONSUBMITTALDATI
NIC CDNTROI.
l•�Jt.v`i 'jl:iK. , "•LI . l��r"j<<..- ❑
ARCHITECfI NEER 11`.�(;~�.,�_ {AR¢3a9ULDINOPERMI'PsINFO:C;:$:
u
NOTES
S=5 Job Description
HES
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—y
FAQ
=�o
Sq. Ft. Floor Area Valuation
APN Number kkpikty Type
S
f.1 Required Inspection
36 s E-(-G:Z-7
C)
PIN
✓Ut U 7
°z,z eU141D/IVQ
V4
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a
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U O
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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 new materials for inspection. Applicant
understands and w'llcomply with all non point source regulations.
t
Sig o`f' p lica - Da[e
All roof coverings to be Class`B"or better
APPLICANT'S POSTING COPY