00030204 CITY OF
L r CUP
nmTneryc DIVISION
- PERMrr NO_PERMIT CONTRACTOR INFORMATION:
On03 of
'
BUILDING ADDRESS: - •
Q• AVE. 04c t, SANI'1'ARV NO, APPLICATION SUBMITTAL DATE
OWNER'SN �O—pa
a �[/- CONTROL#
,. PHONCi I OS7 O Lh(O/�' //(:C ❑7CC .-
r .1, //11 /-s 9
ARCf1ITECT/F.NG�R^ — N�/ISS / —a+c�O 1110
pULDING f'R�T��
S,nl�f.�4re ,Assoc • . '
2141- 3 0- :3
y� • er
hereby
LICENSED CONTRACTOR'S DECLARATION '
I hems affirm dw 1 w licrnand under p (..arm, Job Description
p Z n Y provisions or Chapter 9 myJim..i
P=(= with Section adaffecDivision3ofine BusineenmdProfeseiore Coda,an my license in
pQyp.Y�J 111 fYII force Nd CQ[[I.Lica - . '� ! '-.- 1 ♦,
pee Clan
Data Convector
F u C g
ARCHITECTS DECLARATIONn/ I// FMC /T
u1 r denrW my x -1 e:phenr hada /\sad/ /� W N GG L/Y r..G iP 1 La x/1
dos
fe nal
F-m OWNER-BUR R DECLARATION re '
G3< 1 he y affum that 1 am ee.mpr from the C..".ctoes License Lew for the'
x O .following re .(Section]03 1.5.Business and Professions Code:Any city a county •+
which ngailes a permit to'conarm C alter,improve,demmia .or..pair any wuctule S Ft, Floor Area .I
prior 10 its issuance.Wo"itims the appllcan forsuch permit m rile a signed smanunt; y' - .L 'llllatlon
slut he ie licensed Wlauanuti Ne provisions of Ne Couo-ators Lienee law(CMper9 - - ¢� 19"
sa- Vl
rcommemi.gwith Smdon7O )of Division3ofthe Bosineasand Rofeaiom Cade)re
far he is exrmpt therefrom.rod the,basis fa the alleged e.emption.Any violation or Number�� Occupancy,Type
Section 7031.5 by any applicant for a pcmmm
ut bjmts e applicant to a civil penalty or �
rut more than five hundred do1Wa($5001, - (J
Is 01 as Woul of the property,ar my employees with wages as dteirmla Wrnpemuion, - ,;.a RCyUIIe(I 1nSpECt1
Will do the work,and the mm
uure is not intended sofa,for We(Sm.9Baa,Business -
and Pre fasaions Code:The Canosct l License law dos tut apply to m o der a
Property who builds or improves thrmnn,and who does such work himself ar through ,
his own'.Ploys..provided 1hsa such improvements an nor intended or of aWj for - -
-whe"Wowev willh re the human
prment that
he imine Wild of romplmiou,Nc ' a
owner-Wilder will have dm When of proving that he did nor build or improve for put-:
poseof We.). .
❑I.u owner of the property,am eacluaiv.ly convutin6 with littnsed canuadon to - a`�\ '
.conewct Ne project(Sm.9014,Business mad Professions Code:)The Contractors Li- /1
cense law dos nut apply m an owner of property who burled ar itnpravu thereon,a1nd VVV
whom"ba"for such projaa with a massiemr(O licensed pununl m the Contractors
License law.
❑lam exrm a under Sm. B A,PC for this.aaod
Owner
Data - -
-' WORKER'S COMPENSATION DECLARATION •- - < - 1u
1 hereby affirm un lm penalty of pmfury one of tlrc following dalantiaa: ..
❑l have and will maintain aCenificataofComenuoselGinsumlorWorkervCompen-
workf.provided(or mi Sadon d. 0!the Labor Coda,for the perfr mmm of the
work for which this perms is issued. 1 -
❑1 have end will main Wedwes Compmaa am Immense.as required bisection -
3r00of1h.l.eW ,ode,for nice oflne warts for which this permit is aimed.
My minion swrsama
or
d Policy number art:
'ec _ 0 oad
No.: � is '
CERTIFl O XE ION FROM WORKERS'
COMPENSAn NINSURANCE
.(This section dna be completed ifthe permit is fa.ne hundml dollars($100) '
• IcenifY tlutin the perfolmanmofthe wakforwhieM1 miapemdt isivued,lahall " '
not employ any perm aDe manner oro u to became cubjana me Worker'Compen-
aetionlawvo(Celifoamia.Dem '
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.You should
Weome subject 10 the Wod m 9 Compensation provisions of the L.Wr Code,you must
forthwith comply with such provlsious or Nis permluhell be deemed revoked. - s
CONSTRUCTION LENDING AGENCY. r
z 0 IWrebY aRnntha Nemiaaconnmcdon lending eBency for the perfomwmof ` ••
the work for which this permit is issued(Sec.3097.Civ,CJ "
Lendres Name -
Qe„ ' A
lender's ddmaa
4.
GB� Q I enmity 601 have read this application and sate that 8m above information a . a
z correct,I agree to comply with all city and county ordinates and item laws reining I.
V O Wildings°nswcd°^.and hereby summit.rapreamens.,ef,W,chyme..... Ne.
aWve-mentioned prapeny for inspection purposes.
LL ley (We)agree to Nave,indemnify and kap lormass the City of Cupertino against
"Q fJ habilidra,judgments,coxa sand eapcnaes which may in any waYaccom.larm aid City '••
inconaequnmufthegrantineoflhia,maq. -
(~ e.^1 APPLICANTD .RSTANDS .1.COMPLY WI'fHA1.1.N - NT' `
U z SO 1 F. TIONS.
19 meol'Amlicastaxo car
HA RDOUSMATERIALSDISCLOS RE' '
Wdl Bleeppli" torfutum Wildingmcupanutnrourhdndleh sadous ma.rial Re-roofs' '
u definedby the C vino Municipal Code,Chapter 9.12,W the 1 ealN and Safety
ends,6Yus (.)a � Type of Roof '
El Y. shin . . . -
Will the spphnnt or future Wilding rampart use equipmem or&viceswhich All roofs shall be inspected prior to any r
moofin material being
. hheund°aa erre°^amimanaas dEnWbYtheB.yA .AvQaalitYMmagrm nit ,installed. If a roof is infir
stalled without st obtaining an inspection
❑Yrs __61__ 1'agree to remove all new materials for inspection. Applicant
I have read 0.herud°uv ma.ritli mluimnam,under Chap..6.95°.Nc Cali- underst ds and will 'corn 1 with all non point source regulations.
forma Health B Safety Cade.Scctiom 25505,25533 and 2553x.I undmtand than if d.
'baildimgdoesnotcallmmlyhaveetenant,that it is mY resp°nsibilitY t°nai(Y the°ccupan -
of the.yumme^n which must be met prior to issouce of a Caddies,ofmaw
Owner ,ora t1uma; agent . 1,Data %natore of Appl' ant Date "
All roof erings to be Class"B"or better
OFFICE