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00020065- CITY OFCUPERTINO' '' ' BUtLDINC DIVISION 'P.ERIVIIT' , - CONTRACTOR I1�1�`�}I'LMA`TJ(1�Va . .. PERMIT NO. �'iJ' -OO -Z pip • ` x . - BUILIHNOADDRESS I I . r , , . - ' . - . SANITARYNO. APPLICATION,71M[ AL DATE lied OWN RSN M /yqJ ��'JJ •./ O Q J ©Cie ' 4 /C - -CONTROLis, .• _r PNOnL. S 3 ©co o S is ARCHITECT/ENGINEER s s H RJEDINOPGRAITINIF0 - t , sb r"1 - ♦r •' p2 4� LICENSED CONTRACTORS DECLARATION - 1 herby amrm Nat I em licensed undo Provrvons of CTeprr 9 (commencing s " f - :.Job DCSCrlptlon P=t-w G5 ¢ +a.�U wiNS lon]000)of D' on3ofdm BusnemudRfessiom COe myliunseis In full f0 arW CREEL Lice- Clan - Lie M .. Dam - Contractor r _ " Y. f,' ^ ARCHfIECTS DECLARATION . �•1 �// ^�/ 'l uhdentmd mY Plans mJl be used Public records �•S.' Licensed Professional !. .. ic u t w m ..' OWNER RDECLARATION . ,� m R k $ r e- exempt 1 hercbY afB that I - pt f the Contractor's L ern a Ice for the ° - ' '� '. f O fall - g ru (Secu ]031 5 B ea and Pmf a Cade MY IY m ry + - - 'r S t Floor Area Valuation w which requires a Perm I to w r stmt improve; denodish, or mount y miucture plot 1. t issuance. el rrn the ,fi tf hpermw flea 8 edelate m Natn licensedpunu u N Sion ftheC tr loreLce law(Chapte 9 + 79 Y'�., ♦ O 0' '!L' - p (commencing wiNSecti n>000)ofD'nsionJOftheBUVnen and Prefes loci Code)m that he is exempt therefirom and the hasis for the elieged exempt on. Any vielmon of .p /A. APN Number ' O cupancy,Type Section 70315 by my applicant for permit subjects the applicant to a civil penalty of Ql mare Nan rive hundred dollars ($500). 1, as owrter of dm property,mmY emPloyeea with wages as theirsole compemauon, " Required, Inspections - wdldotIm ork, and Nestrucum is not intended mothered fmselr(SIC.7 W, Business stir Probesuonr Cole The Contractors License Law does nut apply m an owme of propcny who W Ida or rmpmves Naeon. vid woo d«s such work himself m through his own employees, pmvir Nat such improvements . not intended or oRned for - _ sate If, however, the budding or improvement s sold within one yenrofcompletion ,the ownr uildrr will have Ne buNen of provin8 Net he did oat burr m improve for pm -' "" "v-' " ' .. mow) 1 ter of the Property 1 s - ly N licensed contract t tthe yrojecl Sec ](44 9 mProfs Code)n ns Cminswm s4 + ae Law dos of pmpnY who bilds m P e thin d Cho •' con pmj ra [the ontrectn olacenaed punuammlh C ntracroes Wcenn w m - -, s r - f��•• p •t - •, EB ❑1 exam rS '', - B &P fags r 1,•2002 `. , /,. I y- Own ' D m WORKERS COMPENSATION DECLARATION h rcbY fi [rm and r pealty of prjury on of Ne following decl tiom I DING ❑i 1h eandwll nnWnaCnificmeofCmmumelfansu for WO sCDm p a satin as Provided f by Section 3700 or the Labor Code. for the pert mnrme of the r - work for which the. person, is issued 3 '. p ❑ I have and will malnina Workers Compensation Insurance; as requited by Section tied Labor COdgfor Nrprrfonnence of the work Nispermit isieauW. ��� , My Wo number My Workers Compensation Insurance cerritt and Policy number ere: .. n .Cartier: Policy No.: .. - - .= - •. . ' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE a (nil ttidnn dnutb cbmplemdif Nep mtis for one hund ddolla (3100) Or lead.) le6Aify Nmin the dormenceofNe rkfdrwhich,hi em*tisiesued ImAI not employ any penon in any menntt so es m become mbjecno Ne Workere Comps - sokm Laws of Cmfommu Date a Applicant 's. NOTICE TO APPLICANT a If, after malting ding Oemficete of Exemption, you should become subject to Ne Workers Compensation provisions of the Labor Code, you must • forthwith comply with such Pmviatoin or this penult shall he denoted revoked. i- s - 1 ., _ • ,, ', Z CONSTRUCTION LENDINGAGENCY - O O I hereby affirm th at NCm n9COnslnc on lending agency forthrt perfomunce of, ^' + rz... the wink for which Nis permit is issue Se 7097, Civ. CJ Leashes Name _ 1 x [earner Address A I -. a, 7 ( " I certify Nat I have read is f tl t �e Net the move Nformetion s - " W Q As -rn z coned I eg b PIY wW ell ny an c tint midiwnces and mi la s rclati g r u ', V build' 8 t i end heibby amnon remea mu Ives of th s c ty t met upon the - ' r , - " W E., mov ti n d propeny for inspection Purposes s • (W) .,In t ave. mdemmfy and keep harmless Ne City of C pemno age nit l • O f,J limiloinii judgments, cosuand expenses which may in my way C— against said City. " y. W in consequence of the granting of thus pemit. • ( . �7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NoN.POINf - - •' f..7 SOURCE REGULATIONS - y ,,, _ - G Signature ufAPPllcanl/CDntnctm,. ... Dale ' - %ON r 1 ' HAZARDOUS MATERIALS DISCLOSURE —� f�I1� UCG LJrh� Re-roofs Will the applicant or future building mcupamslorc Drhandle haraNOUa martdel ` as defined by the Cupertino Municipal Cody, Chapter 9.12, erW the Health and Safety Crude, Section 25532(.) ` Type of Roof : , • a. �, L Cl Yes N - ., Will Nc appbcenLO wre buddingm pant use equipment rd eel which whit hasardousancontnm definedbylhe BayA Ai,Qnalty Management , . All roofs shall be inspected prior to roofing material being installed. If a roof'is installed "first an- inspection ,. • °ice " "' ❑Yes `®,No r without obtaining 1 agree to remove all new materials for inspection. Applicant, d tin erstands and'.will �/ 1 hav aru a tromriala reryiremems under Cho 695 of the Cali-, cbmply'with,all non,point source regulations. , [mina H St Sir Cade, Sections 25505, M533 ind 255341 ndcmund than if the sn Iii ._ n' ' building haveilen ithn it is my respomibilily noli(y Ne mcupam -� •' of It « on a st be ofaC i rcpt cy - " - Signature ofApplicant Date,, owner De gent Dam` el 7 All to ofcoverings:fo be Class "B" or better. ' OFFICE