00020115 CITY.OF CUPERTINO• . , - . .. . . . PEWIE NO. '
_ eaiiniNsorvlsloN PERMIT C0NTRACT0.1K-I;�F0,RMATI0N-,
'V BUILDING ADDRESS
ILO ,4 I eq I I K n u SANITARY NO APPLIOATIONUBMq ATA
WNER'S NAME: 1: ! • �"� b ,.V , _3-r5,
V, . � � '- Q(/,,¢(•Sryry ee/A��"�G•. , N/C ,,CONTROLM. •.
P ONiv ISGJ�'r, .J✓L✓V�` '', S i El
h
.ARCHITECT/ENGINEER _ • , RI sDIN I F
5"1 pc
o N 3 " LICENSED CONTRACTOR 5 DECLARATION r. I -
•o Z= I i O d)of that l am licensed Me Pro mane of Chipm 9(connnetei 6 - , , Job Description, -
r„w m wmNS L n9000)ofD' " 3 ftM Bui dPmt on Cade aid Ylico i t t. * '
mfall f and eRttt. N �` •r 9
Lan G. �a. e�nl oar rG
Yxl'3 LL,Fj, Dale - cumnactu ''
ARCHITECT'S DECLARATION. -
ce Wq_y / nil rstaid my plans Nell bu e used Pobl c records R "
Licensed professional S'. . _ • r' '
OWNER-BUILDER DECLARATION
hereby affrtn that I not exempt from the Contractors License Law fm the
F O follsomig,actum;.-(Section]031 5,Business and!Pmrewom Code.Any city or worry
Cc witch requires,a permit to construct,mass,improve.demohsn,in repair my structure - ;Sq. Ft Floor Area r' Valuation -
LL prim
1.its also requireslne applicantforswm
hperriut filee signed rmm
ieerit
^
dust no
licensed pdrounit 1Me prorisim.ofthe Ea uanor L Law(CMger9(commencing withSection 9000)ofD i,i.3 of do,Ihisinessandlooderaomeddma ATN Number - Occu ne Type
Net he is esopt therefrom and thebuss f me alleged exemption,Any violab of `p y yp
Seco 70315 by Y ppliam fn a Fertm, bjatethapplicant to acvil penalty of <��3 _ ■ t
not more than five hundred dollars($50(3).
❑1,ore owner arthep pony aper empinyen wmt6w.ge¢uthev orale cnmpenaahan, .. Required Inspections
will do lesions Cause: oCoer¢noti License
Law does ofBuumrea -
end professions Code no Contncrors Littnse law does not apply to an owner of. 'A.
property who bis Id¢or provided
u t such improvements
aril h da h to dm r esof f M1 "
his own employee pmvded dustsuchreproe i within of tended R red fm
salt If,h"I" itheveth hmian ofd omen then hnevem f pe or the r ,.T t
ow budder will lieu the human f p vmg shat he did not build prove for pun L
of sale) ^ '
n L ore t r of the prapenY e 1 ively connecun8 w W httnsW wntrecton to //("�
on t the project to 0044 B e and Py who Wild,
Cod mpro a vmem and
J
cenxe law des w a ply to m u er f progeny who builds r improves Merton end I a
wr,conna s projasa wmN econtrutor(x)liceeed punumtto Ne Canunctors „ / '
Licensor w.
13 [.a sem S=" ,BkP orthistuson
Ownm oma - .
WORKER'S COMPENSATION DECLARATION
+� ihereby e01fm der Pentory ofificte perjoforyoneof thefollowingmg arket'hom.
❑Ina e d llfor by, eCertificate of the ab to inl6msum fie Workerscempem
•sora provided for by 5 cd n 3900 of the Labor Code,for sM1e performance ofthe .I
work for which this pe t sued.
❑1 have and will maintain doe
prWriters Compensation firsurawork
which
h his per by Sumcdn
MYWt the Labor Cotlgfor ndrc nerNrinurne and
work fnu which Nie p<nnit is isauM.
m 'MY Worker's Compensation Insurance carriereMPaloc number art:
Carrier ' ' PoIicY No.:- ' ' �
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
(Th is sximb men not be completed if Ne permit is fomite hundred dollars(5100) x
or less)
not., Loy my Nat in in
my rmmur of Ne work for subject
o the WhItasuCompe,ll e
union .any person in any mentor ao8smbecome xubjmrao th<Woker¢'Compen- .. '
Anal ant o(Celifoeie.Dow p
.Applicant,
NOTICE TO APPLICANT If,utter making this C-e Geese of Exemption,you should
become subject to the Workers Compensationpro ns of the Iaba Code,you must , _ -
anhwith croup];with such provisions or this permit shall be damped invoked.
•CONSTRUCTION LENDING AGENCY -
L� `L hereby affirm Nat there is aconstmrecto lending agency fortbe performance f
aZ. the work for which this permit is issued(Sec.309],Civ.C.)• ' S' • {
Ew Lenders Name . , •, r ,
Lenders Adme. v.
e
WQ 1 ertify Nm 1 havjd iwuon and stale that Ne above mfomuuon s mplynd o my b ndesa tui la s leu git ,�iz, build necon uuctu umd prcsemt vesofWsc tyt me uponthe r abo<nor dism,hyn ke E., Y (W) gr me h le. theCityyac fCpemos6 sa.cstc t h h ay nuY weY a Smutsaid Coyinto va riceofDER WILL
t. r ♦ -off/ `I}'
[� Oe APPLICANT ULATISTANDSAND NII LCOMPLY WITH AILNON=POINT -
f..7 z .,SOURCE REGUTATIONg.,r
Signarumof Apphcent/Conuactm ., �. Deis =t /0 ti/.7/t/VCG A' ( Y•))
f RDOUS MATERIALS DISCLOSURE J
Will slit milcant or future building omupum store orlundle hazshais maenad Re-roofs '
ori der, d by the Cupeon M mpeI Cask.
od Chapter 912,and she Heddt and Safi ty `
cade.saann ssTypq of Roof[I ye, p ,
Will the pphunt f t wmiamgac p i eequPme tarEe meawM h _ All roofs shall be inspected prior.to anyy roofing,matenal,being
- nest havrd gconwnn is dfined byN ByAt aA QdryM age ani; installed. Ifaroof isinstalled'withoiitfirst obtaining an inspection
District? I agree to.remove all new materials for.inspection Applicant
yes
I a Ne hazardous materials miwrtmenu under Chapsu 6.95 of the Cali-
understands and will'comply with all.non-point source regulations.,",
fano d .feiy Cade:Sadore 35505,25333 and 25534.1 anE =d Ws d the
huild gd nently ha t sol uuuus my mponsibdiry nmifY the orcupam
of re9u s 'hen t t isuence ofnC erre
- ,Signature of Applicant , Date
Owneror authorized egem,.a Date , ;•+ -
Alf roof coverings to be Class"B•'or better
o
'OFFICE