00020123 ?CITY OF CUPERTINO_ PERMIT NO.Aa.
^;nL11LDING DIVISICYN 1 `. PERMIT:;... COINTRACTOR INFOItMATiON '
BUILDING ADDRESS: "i" - r -0S. O'z O 1
(S(y ^ _ s SANDARYNO., APPLICATI^O�N S1UBMITCT��•/p�A�{TE
O NF.RyJ SyNAME:`✓"1I _. �••', - `r��..J 1'. 1 1
a6'�/'� 1/Y�..�� j ,UC -CONTROLA
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NOW ARiNE `
+ ^ BI)ht)1 O E ndI i r0
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' ' h^rebsLICE mCS DECLARATION
Rmded I aEI
OR
O Me provisions; f Chaper 9(mmmwe
Job DescriptionZ= "
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wdbSconm700(yfDi,ian.3 file Bus sand Prof - Cod and mYlicc r
in ruil force
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„ ARCHITECTS DECLARATION I
1ndemtard or,plans shall fenced uPublic records k
r� Wce ed Profeauovlnef
9,. .
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+•7 , OWNER-BURAER DECLARATION
t.Zx a •, 1 hereby aTom that 1 am exempt from the Connector's L Lew for the v i
�F C following onnoun.(Section 7031 3.Business and Professions Coshc Any citylor rnu net, I a
which req tree a perms to rnnsbam alter,improve demolish r repur any structure
3� Priariudeissuance,ma0regarresthripphcamfarsaehpemmn;fleaagneduammmt .Ft.Floor Area L Valuation
Net he slicenretl punuem mNe provisions ofNeCmrtactof L nn,Lew(Chaps 9 '-"t :'S,�A
(commmclagwihh Swbon]000)of Drvtson3of Ne Busimme P fnxi mCod)
i Net he is aempl Naeform and the basis for the alloged anor)ELOn.Aar violation ofAFN'Number - occuancy Type
Section 7031 5 by any applicant fm a famous subjects de appl cart to a civil penalty f } r '�
not mon,Nar five hundred doll.($500)
❑'1,as owiierb(the prapcny,mmY emplgtte wile wages ae their sole c0mpenanion;' , • ••i' Required lnspectio
and do fewmk,andsh ro octoses mLicersoroRered(mot apSec .an Buaa,ss
k and prof i m Code The Contrdve m h,,icons laws of apply r f
property h b Ids or p the on, d h does snort wmic himself Nrougr 11 -
his own employees.Provided Net such
ve mm it sol ts tie t i dad R red for
.cele, h r N 'am”"g o Pro t Idwithin a year f ple for
the �lp/
ow W Ida ill heave de birds of proving that hx did t build improve fm pb > _
nm f th<P PertY em d u ly ono- un8 'N heensed conaact to
onanuct,d project(Sec.]W4,Busincar d Prof ions Code)The COntncior's LI
cense Law does n t epply�to an owner of propenY ho bmlda m immovea thereon end , ,�r. �/• / .. ,'
'.rr whomm f uch pmjacmwiNecontremor(s)li<enxd pumvmto the Conoumrs .,• .e .y: t 't
�• Liu
❑1 m. q4 B
y Cf. ,•m
7 'Owe
WORKERS COMPENSATION DECLARATION -
1 h by fi under perWty of Rptvy me of the followin6 dalanuoha
Q
autism,
e d provided
by Section
37 m of to Labor self,for
Por WOrker'r offfie v
sari m proidhi f`mi Ss issu 3]00 OF Ne Labor Code,for the perf0rmmtt of Ne i
work far add ill pmts ssued.s•C
' ❑I have add will mainmin P'oheh Compensation Insuruice;as required by Section 't• 'e'.p. r ' •):. a,
3"/00afthe labor Code,fm Ne perfomrance ofdre work for which Nis perrnit is times, -
s 'MY Workers CompenanOn Insurance carrier and Policy number are:
Cartier: Policy NO..
' ,te
CERTIFICATE OF P.KEMPf10N FROM WORKERS'
'a COMPENSATION INSURANCE + -
(Thin aectine need nm becomPleed rfthe Pcmmtrs(Drone hurWre4 dollars($100)
Icenify ilurin de performantt of the work for whichN sperm isnWet.I shall o _ _ •' -
not employ any person n any as to becorm subject m the Workers'Compen- , - '!
mtim Laws of California.Dsle',
APPlicmi
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should"' - •
become subject to die Wml Compenau0n p isions of the Labor Code,you most
forthwith comPlY with aucM1 provisrms car Iris pnanit dull be d«mcd ievokcd - - •
z )• •` CONSTRUCTION LENDING AGENCY
0 � I hereby affirm that then,is a,cmato.cml rrdn6 agencyf ass,perfomence of -
i7a- .~moi t e work for wh ch this permit is issued g 3099 C'v.C.)
Lender's Name '
> Lender's Address- , - - - r - •` i -
_
. certify o c I have reed PP Mamie Nenh bo mfommmn is
pq, erect 1 gree to rnmPIY with all c ord" ncea and atm 1 ws relet n6 to
buildingco^sWence mW hereby au miu et
ofthis iyt-enkr upon Ne - -
U•Q shove memroned property for mapec dpurposes - + s
•W " (We)agree to+uve,car mnif d k harmless the City f C rtino a t :•
F Yen P Y P< Gams
��U liabili o,e 3udlermus..caaiamd expenua wh ch y in mY way 8 a said Cny +•. ��Q � '/,
oyes W m cousequemo of Ne granting of Nis pemmt
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
,SOURCERT;GULATIONS-•r
HAZARDOUS MATERIALS DISCLOSURE Tn Vd
Sigvturc ofAPPliceHAZA DO Y One 5Jy(� CGa� '
Will Ne aPPlicarto Pomre building wcopem emn,or handle notorious material - r
'as defined by the Cupenin Municipsl Cade.Chapter 912,and the Health and Safety Re-IOOfS r t
Cade Section 25532(.) , - �,,. Type of Roof
Will rh ppfcan[ rf future building occ pa i s.equip a tcar deviceswhich All roofs shall be inspected prior-to'any roofing material being
emirharard a aite.mmo niseadepend bytheBe,Mut A QualityMmi.gernam install ed.'If'a roof is Installed without (first obtaining an inspection
La ree to remove all new materials for inspection:, Applicant
❑Yes '. ,ANO � - - g s
Iv< hrardous materialrreq rcmenu uMer Chapu 6.95 of ale Cali.
understands and,will comply with all non'point source:regulations.
foram eel sty Cade Sectns 25505,25333 and L55 lenders lard Net if de
build d c 0 ha t em thu ism su a -
B ^Y Y, W s il'ry War.( the.Irlaut 1, -
of requi ora suar¢e I -
" wnm or aathnrirea.gem - '.mte� signature of Applicant
o •'' Date '
All roof coverings to be Class"B"or better '
OFFICE