00030199 CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: , dOb3� �j I/ .,
BUILDING ADDRESS: _ - - 1
SQ. 4 E YlyN $ SANITARYNO. APPLICATIONSUBMTTALDATI
L OWNER' b11'/1W14C .. • ��SBO
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CONTROLis
PIIONC: {07(f • G7 b'.-��U!/
ARCHICI'/ENGINEER 1c
- r INLDINO PERMIT INFO
S/�t/CtAvf� Assoc�, s '
z0 v ul= LICENSED CONtRAC10R'S DECLARATION :" LbG �.
.O. _Q hemby aRrm Nn I un hummed under provisions of Chapter 9(commencing Job-DBScriptlon
.F� with
Section?000)°f Division 3°fdw Bosi...x W R°feuiou Code,and my limrsm is ,
in full for"and effect,
E:m < Uoure,cf.. LION
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to—C.M.—
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•.ARCHITECTS DECLARATION. W�YI/DO� /D�^"K �QIi—y L/7'ya�a -": '
ndertwd my used u public
medid. '
Prefeui 1 � •
W— OWNER-BU DERDECLAMTION
a 1 hertb eRrm the,I em exempt RbmNe Comnnor's License Lev(m the t
D following mature.(Section 7031 S.Business W Profmi°ns Code:An !
ycan sumum - -
3 a
whicht itsiona a Permit a�ims the aper,i applicant forsu h,rouFoun I fi repair ver amuanr S- Ft. Floor Area !!lIII
thathe defused c.Purl auquirs Novisisothe Cohpemu,mfiausele a I-nedmmment q' • V InallOn
Imhelelice with
Pursuantauthe provisions of the Contractors Liceea Law(Chapter,Coe) r
(c d he is xempth Swtio re Led!the
basis n 3Or the al aged essaxe and Prefiesson.Anynin CMG)m: t
w,Section
is exempt anyap li w the ware Or the alleged palmation.aci violation or APNONumbe�� ccupancy Type .
am mo than by any applicant for a parent mbj«u the epplicwnO,'rule penshy of '
pt mart Nen five hundred dellen(S500). - •' �.T
1,,sectnerorBUPwpenr.ormyemploye�:wi,nwagpa.,meir:elpwmpe�;adon. Required Inspections
will do the work,W she'nothe sire is Mt imwMd m Offered fm We(Sm.70m.Busiuu -
and Prefeuimu Code:The Confucians License Lew does nor apply,o an owrur of +
propety who builds or improves Nemo.,and who does such work himself or through If
his own employers,provided that such improvements are in inunded or offered for
We.lf,however.,w buildingmimprovemrntis wM within arc Yorofwmpleti.n,ire y' -
' ,OwrmnWildm will wve,w buNen of Pevi06 Nat w dW nm W ild m impmvc f°r'pur-
co I,a onwrier of Project
property,,H exdusivdy conuw,ing with licensed cntainers U.
-
.,
construct chatam1111.nan-susiussaWRofeWWi C°.1JTw C°nf¢mre and
who
mewd�for such plytow oath a ofproperty who builds orimproves,wrtan;ens E " f /•
who convects for projects with econaactpr(O licensed pursuant on the Contiacmea
License Law.
❑lam exemptunder5m. ,B&PCN1,dsmawn
Owner Da. •V v
M ° WORKER'S COMPENSATION DECLARATION hrtbYafi muni p WYOfMj ryon of the following dwlva,iau
❑I wse and will meimain a Cenifrneof Conserv to W f-inaurt for WoheM1 Compen-
ueon,uprovided fm by Section 37M of the Laver Code,fm,he liudi mence of the '� t
„ work for which this pe.I,is issued.
❑I have and will maimein Worker,Compenatlon Inewhow,es rryuirtd by Sa,ion '
37(0of Ode,fm drc rt.nmr.e Of dm wort for which thiepmni,is iaued. r
mpm ranee Brand Policy numwrwe:
mou antic
Policy No.: "
CERT ATE EKE ION FROM WORKERS"
COMPENS ON INSUMNCL•
(This sect nneed notbecm°Pleadifthe permit it forum Wished dollars(SI00)
m lop.) - -
Iccrt'ythatm lheperfmotxa a°f Newodforwhichlhispe,milisiswed,1.WE..employ Y Person in wY rrennpr w a_s to became subject m Ne Worker'COmpen- - -
sa,ion laws Of Califomiu Dau.
Applicant •.
NOTICE TO APPLICANT If,after making Nis Cenmcau of Exemption,you should - ..•
become.ub*t,.tan WOhees Compensation pwvisions Of d e Labor Cade.you..in -
forthwith comply with such provisions Or this permit shill w demand msoked. -
Z ' CONSTRUCTION LENDING AGENCY
p I humby a t.Nn,then is a conatmcuon lending agency fonhe perf.mun¢of
z Ne work fm which Nia p coed is issued(Sec.3097,Civ.C.) -
a ���++ Lender,Nurse
y 1'nice,Addrcaa -
W� 1 Geri fy Nu I have uatl thu afildlicasion and sum the the above admiration is
V 0
correct 1ague to comply with allcy.rd county mdimmou and sum laws mix ngm a
building construction,and hereby the' repusen,mives Of this cityto enter upon the
Mrve mentioned property for inspectionpurposes -
�+ F` (We)life muse ,ndemnfY and keep humlesa the Cil,of Cupcmn°.Bens,
Q C.) liebdifes,ludg,renu,emu and cape...which may in any way mems almost aid City _
;i+. (xl in consequeme the gmating of this pemut.
E'er AI'PLICA U DF.NSTANIIS ANDjL'UAX,4Mq.Y WI Of At.[.NON.P[HNT - r
V ..ULATIONSI + -
S,exuarcufAir,lican , ,m r Dam: •, '
HA2A yOUS MATERIALS DI LOSURC r
Will Nc applicantyy uboubuildinflumol nt t.mit adhibunammernemdal Re-roofs "
- o defied by,he CuperQna Municipal COdo,Chslx 9.q aM tan Health and Safety -
Cot.,Secponu5aua)7 — Type of Roof
. -?Ya'.
Will Onii'lie:m or fume,building Occupant use aq°ipmem or daviras which All roofs'shall-be inspected prior-to any roofing tl material being
emir h..'d air confuehunn Udell t Bay Are Air Quality Management installed. If a ,roof is installed without first obtaining an inspection
District? I a ree to remove all.new malonals for inspection.'�Applicant
ElYeiO .e e ,
Ian,a.adthe waardoa,maeal.miiiwexenrunder ers ds and will I with all non point source regulations.
forma Hwlm&Safety CMB,Sections 75505,25533 and 25536C IA rand N f sit
building doer me cumuli,haveamnanh thin is my tesponsibili,ymnaify Ne pent
of the reyumemwts which must be met Prof.hat a ea of a Cenificem Of puwy. '
Ownmmantimuc agent Dam 'gnatureof plicant 'Date
` A roof coverings to be Class"A"or better
.0