00030197 CITY OF CNERTINO . ' PERMrr No.
BUHMINCDIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS,'
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Y e NIC C/ CONTTROL#PIIONC, .. -77 rrj171T/// Z.r/ ❑ ./'O.y/
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ARCHIT Cf/ENGI EER , BULDING PERMIT INFO
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LICENSED CONTRACTORS DECLARATION '' 13L_I p
tJ Z_O I hereby affirm that 1 w If miler previ imu of Chas'.9(mmmencing lob DeSCrIptlOn L•
t-w wain Saban l0pp)of D' Jof Ne Busistena std Rofenton Cade thd mY lice pens * a,
in fail forceend cffa, -
P a g L,rtnnG.n Cminscum
ARC
,Q�t�l��Nfv 6U/NDotJ�O� R�PCACCIYIG
Lou, Convacmr
ARC ECLARATION
j,5 1 undnuM my plena I W u' u public records t
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uu
OWNER-BUR.DE ECLARATION '
1 hereby lur Net 1 un exempt am Ne Contrectoka License law for the -
,u o follwdng .(Saban 1031.5,Sol s and Prodsou m Cod:Any city or mua,y i "
3 m winch lupine a permit to minimum, es,improve,demaiN,m repair an aeuchom
mnxin ance,dm y Sc. Ft. Floor Area ,/
prior requires the plicaefmsuchpermittorilea Law(emitter
I "�S QOI'0
- (anethat nt lice red woo S.umflt Nepry�y'[l dmf the Canescultioanmlaw(Clapn9
(cat he
ingwiN Serefion and the iaiiiofr oldrceged emenMf4o A.,vitim.of y�
So he ie campy Nenfrom and Ne.permits Nc alleged eaemard to Any violation or AFN'N bins iyf •- O Cu anC Type,
• Semen 7031.5 by five
hundred
forapemdtsubanthe O `00 Y
1 epplieent to-civil petWryof
not mart Nen Eve handfed dale.1 co,1.
❑I.as owner or Neprepeny,mmyemPlaree.wiNw.gnpetnalesolemmpenm.don, - Required Inspections.'
will do the work and dyes structure is net imcMed or offend for We(Sm.1066,Business
and Profesdom Cede:The Contractor',License Law deem not apply in an owner.ef
' property who build or improves thereon,inn who don such work himself or through
his own oweven,a,provided!Nan such improvementsismaid thin era intended moffem,phoun,for t '
wa,ILholdhr will
the buildingburden of
is at he did none tbuild rimpro lefor
cofsaldr will have the burden or proving that he did not build m improve for Our-
the
ro�awm).
❑1,as ewser of Ne property,sm exclusivelY convactlne why llCensed convectors to
comvoct the project(Sm.IU44,Business and Professions Code:)The Coneacroh Lt:
cern taw does rot apply to an owner of pmpe.y who Wilda or improves Nermn,end
who e. w.for such project -convnpursuant rsuant to the ContractorsLicen1L
❑lam hemp undo Sa. - .B&PCfor Nis rayon '
Owner .. .. 'I:• Date
WORKER'S COMPENSATION DECLARATION
. 1 hereby aRrm ands penalty of peppery one of the following dedthedone: . . '
❑Ihev<and will maintain a Certificate of Curator on sef-insure for Worker's Compere- v f/•�
union.pe Provided for by Sadnn 37W of Ne Labor Code,for Ne peffomaae of no \Vl
work for which Nim penrtit is issued.'
❑1 have'and will muinuin Wmen's Compeneuion Insurance,is inquired by Senian
J) Ne Code,fm Ne fine work for which Nis permit is issued.
Y n ti mom
c and Policy number are: t
Carrier' n " •' e. .:e, ..
CERTI ATE OPEN MPfI FROM WORKERS'
COMPENSATION INSURANCE
missatian amt hectmplemd toy.pemdl in formse hundred dalars(gloo) -or fear.)
. Icenifyth t in the pdurm remid Ne wmk for which this permit is issued,i shall_ '
non employ any pe on in any m mer so as m become,vub oc,no dye Wohern-Compere- '
Crimper-
union Laws of Cdifinu m Dau en `
Applicant
NOTICE TO APPLICANT:IL-fill mddng this Certificate of EcemPtim,You should'
hecomc subjat to the Wodnfs Compensation provisions or the Labor Cade,you most
forthwith comply with such provisions or this pnmiuhall be domed revoked. • �„
CONSTRUCTION LENDING AGENCY
0 0 Ih by Nn the,dome v a cannwcuon lending agency for the perfor once of - s
rNe wmk for which dim perem is issued(Sew 3091,Civ.C.) •' L
F. lendr's Name
al tenders Adrircma
WW - I terrify Nu 1 have reed this apphtcu on and cute Nat in.above hill.tion is91.
Z;) z. torten.I agree m imply with all city and count)ordinances and sum laws reining to -
U bihim c=tcdomand hereby.uthodmmpnsenutivesofthiscitymenterupon Ne - _ a
ebov,-rommunind p n'"Y fee imperil.puryom'.
Fay'E. (We)slime to ave,indeemify end kap hnmleu the City of Cupertino agdmt ..
0 t,J liabilities,jwlgmcns,mets-red cxpenma which nay in any way accmeegainst said City '
in conn uencc of be _
W rand. '
t+ 9 g g of Nix pcmdt.
tZ APPLICANT UNI'%1NDS AN WITH ALT.NON-POINT
BOURC 0, ..'1'10 . ..
U
NS.
z '•
Sign pploowtCa. til ., Dem
HAZA DOLS MATERIALS DISCLOSURE': "
Will the applicant Zr future Wilding acupent store or handle Notorious materiel Re-roofs
as defined by the Cupnim Municipal Code,Ch-pier 9,12,end the Health and Safety
Code.Saymn 25532(8)? _ �•— - Type of Roof
❑Yes U'er
Will Ne s"Re-m or future Wilding occupier,use equipment or devices which All roofs shall be'inspeeted'prlor to an yy roofing material being
coal hawdour an commit ass def ynhe Bay Ara Air Qudiry Mm-gemen' installed. If a roof,is installed without first obtaining an material.
D.mn.n0 I agree to remove all new materials for inspection. Applicant '
�. ❑Yu" � �' No '" d
Ihave and me heaardus matenW requimmenu under Chapter 6.93 of the Cali un er, ds and ly with'all'notl:point-$onree regulation
Nome Health Al Safety Code,Savmu 23305,23333 and 25376.1 aMvsund tNo if the -
building does nm currently heves a¢n-rel Nat it is my respanaibility to naify Ne Deco -
,of Ne mvinuerana winch must he met prior to issuance of a Cenificme of Occup y.
on�neroraaNmi,eaagedt - 19, attire.ofA litany - - Date
All rob coverings to be Class"B"or better,
OFFICE