00020110 CITY OF CUPERTINO - - i PERMITNO. -
BUILDING DIVISION',. • PERMIT ':, CONTRACTOR XNFp�MATION
BUILDINGADDRFSS —0 1 I O
- SANI'PARY NO. APPLICATION SUBMITTAL DATE
/�'��. / f _
.:.' OWNER'S AME.'. • .��1 ' U _ a.
t L ///•�p�/�) N/C 4 CONTROL#
PI ONL.' -530V_
'fDrNO PERMIT INFQ
-�.ARCNITECTIENGINB[?R0- - , , • ,
t
NZm 1 '--
FDi LICENSED CONTRACTORS DECLARATION•- .. ," " 1'
oz�.❑ *' I herebyiRrre Intl Iccnred dem ms of chapter 9(comre ng. ",Job Description
p w with Sanon7000)of D' so 3 (the Bus rte aM Rofsion Code arJ ylicc se 15- (/�� rk
o a anfallLicensfares e
=fie=f /}� / rte' q rVl
License Cls Lin# ' a 1 ol/r
>t vc � Omc Connector
♦5 o O Q t l ARCHITECTS DECLARATION
I d rniJ mypWsshell M1c used-m Public records 's - '• s'�
Licensed Pmfc.arml - • S a' .d'^ - - . '.
�ure�m OWNER-BUILDER DtECLARATTON - -_
4Z< 1 hereby alrmi that I am a o pt from 0e mc
Conttor License La 'for the e ,
C followin8 (Sal 703 15 B -ss and PmRrsiov Cade Any city or county ^ - -
Fa
which Pe tt wa J.er,,mpm.e.aemourn n p. r tmaar= SqF(Floor Area Valuation
pro m t n .Js mqu theapplicant for such portion to flee igned ams ent -
atDat he slcenred pmaumi to the provisions of the Conrncter's Lt...Law(Chapter 9
(cammrow,win See..7")of Division 3ofine Butinees and Professions Code)or APN Number 'Occu CMT e
that he is exempt therefrom aM m=auto for the alleged emmption.Any violawn of y YP
Section)0313 by any applicant far 6 pemdt subjects the aRlirmt toe civil penalty of •�'� s �, 8 y 't '
nm mom man five hundred Oollem($300): al
'plan owmr of me prapcny,or my emPloyeuwthwagesurneiisole compenuun �..;' Required Inspections,,
will do to work,and tMsnucmre is nor inmrded proffered far W.(Sit.7096,Bear ns „
and Profusions Codc:no Conwood License law does nor apply to Are owmr of, -
property who builds or improves thereon,anal who does inch work himself or through ^„
ow m 1 eu Provided thin such ire rovements are not inteMed or:ofiered for - '
his rt e a er •Pro ed p
We.If,however, have thmganmprovement lsmldwithmone uild umprovettor the
Wilder will have the burden of proving rent he md'not build or improve for pini •1 v' ^' ., "
of seleJ. - 't
o L u ow.a of me Property,em eaelusmely comrecung with 1 cemr M c tmcroia m% / 6
t theP roect Sec:7094 Business end Professmne Code. TM1e Conaacen s Li- t
cense Lew duce not ly to an owner of property who builds onmmavee thereon:and
License tic projects NeconwaoRsl licensed pumm�uo the Contractors
License .. ,
❑lam xe Set.x B&
P is Asan 4, ,
a
� 1
t
Owner De¢ I ,
_ ,r WORKER'S COMPENSATION DECLARATION
(fi d f pfine followin dcduatim;w,1 haver
I and a rm un a nett o ane g
Y R Y R=lufY
swim,
endwdlmatniy eCertificateion37W of the Laboart r
Code, refer Worker .Ce of the :
ohM1
saaon,as rovided for b Section 3]00 of me Labor Coda for,the rtommnR a ..
P YR
'work for which this perms is issued. i - - - -
❑1 have amLa N maintain Worker's Comps sin 1 franca required n i Section
My rk aCo Code i theprancetnc= ad kfar wh lithispennit is iaauW.
My W k t Cpmpens t I rends crena and Policy numbs are: • '
-Cam r
Policy - '
CERTIFICATEOFOMPE EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
('1liis reaipn need nor be complued if me Farad!is for me hundred dollve(5100)
unless. i,
:I reality that in the performance ofthe work for which this permit ii issued,I shell
not employ any person many manner so as to become subject to me Workces'Compen-
selaw Laws of California.Date
.Applicant . r'.
NOTICE TO APPLICANT:If, to.making this C=mficate of Exemption,you should -
become subject tome WmIaner Compensation nomms of me Labor Code,you must -
forthwith comply with such provisions or this permit shall be domed revokW.
Q , CONSTRUCTION LENDING AGENCY a Ihreby mTrm that me. strucion Lndmit agony far theRRo. of
i••i me k for which Nie perms is issued(Sec 3097 Civ,C.)
bailees Nam=
a NLender Addre
Lo I..if,that I h:vc read Weep 'cat n d i mat the above infomuXon to ,
� z, comae' I agree m co., with JI city i es and ...o laws relit ng m -
buildmgconstrurdmi.a hereby ams rex em m oft# tyt wderuponthc
L.) aW< t nail pro,ny f -Ren ti Ne a.
t W Fy (W) grin m s e d,.ify.rid keep harml ss the C ty f C pert no, ainit
V llabl'ferj dgmems.cost;and e penes which may inmy wayarcmealladinsts.id City ' G/X>
[� tAPPICANT UNDERStANDS AND WICLCOMPLY WITH ALLISON POINT #
A4 in,
v, SOURCEREGUTATIONS. "
-sig_ m afAppficartiCminator - Dare �tJ �- a9�%7x7�-(.JCG
HAZARDOUS MATERIALS DISCLOSURE •'
Willmeapplicammimureboilding accupaamore rhrndle ounidau tioncriil Re-roofs
m defined by the Curenino Municipal Code.Chapter 9.12.end the Haiti and Safety . - 3
•Cad s t z553z(a) Type of Roof
❑Yes N -
All roofs shall be inspected prior to n
an roofing mateal'bemg -
Will theapplicant f um Wilding occupant use egmpme t or d s which,
y
'mit hicandow,mcoamn L t defined by the Be,Area Ah Qmuiry Mmge tit installed. If aroof,is Installed without t-irst obtaining an inspection
°"""' I a res to remove: riew.materlals for inspection: Applicant
❑Y a
lbeve raid= a mardousmamixh req nls.aMcr Ghaptor 695 of me GJm un erstands"and,will comply wlth:all-non point source regulations.
'amu He S e Code,Sections 5503.75313 aid]5334.1 understand mel if the } + -
.1.dding pun -ally have at ithJ III mY ruponsibilii mnaifY me occupmt - s '),.,. 1
oft, em si 'a m's a ofeC tate cep - '
Signature of,Applican[ 'A` Date '
Ow aumonzN.gent Date n - .. •' -
All roof coverings to be Class `B".or better
r .^•' "
„ OFFICE,': .