00020130 CITY OF CUPERTINO PERMITNO.� .
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:, 7 'I^I
EUILDINGADURESS: `� V O •V ,� 3
IreSi SANTI"ARYNO.. APPLICATIONSUBMPITALDATE
QWNER\ NAM&
L NIC CONTROL#
YIIONL
63 0
AItC—.HfrlllliNOINF.ER ULUINOPHRMI'GINFO
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LICENSED CONTRACTOR'S DECLARATION - '-
z Qz I neat afr d'aI l alu lizwd ureter Gene 9 rwmrreming -
FOI, with Secsim TOW)ofDivi.ion3of the Busi°ns and PofasloJob Description
4 C" ons Cade,and mYlianaeu ;
gO�p in all force Cler effect. Lit.N
co►r .
3LL� D. Gmmw NeW -I garage✓
AKCHITECTg DECLARATION
j, 1 wdenland mY Plans shut W used u Public records ��, .
¢f
u.o,a ureued Preremtoml ,. �'
OWNER-BUDDER DECLSRATION -
FG Z G 1 hereby affirm shat I am uemp,from the Courn eor.License Law for the
Oo following assort.(Sermon 7071.5,Business and Promniom Cade:Any city or county
e 3 z wldch ream's a permit m construct ashser,improve,custodial,or mp.ir any summ. ,
Priamiuio.,also requires she applicant for such permit m rile.ugrrrdzurelsvrc. Sq. t.Floor Area Valuatio
Jut he is Reamed p,dress m the provisi ma turtle C°Im.cW.lxrnse law(C1syse9 J
(commencing with Section 7=)of Division J oft Buunw eM Profmimz Catle)m I -'
that he I.earmN thearmm and use Will,for tn,.11c W emotion..:Any viclaVre of A!!N Number . ' Oc upancy Type, )
Samoa"31.5 by au,eppli.1 fora perms mbject.me applicam to a civil.our a(
rot come Nus Eve hYMrM dollu.(531101. -
I'..°�""rar'"`Prope'Y•amy""p°'"'wiNw,ge.astheir sole eompem.Ja°• Required Inspections
will do the work,and the Structure ism hooded car intend for We(Sm.QOM.Buumss
and profusions Cods:The Cmusctor'a License taw does not apply to an owner M
property who Wilds or improves dament,W sub don such work himself or Itmm h -
his own employe.Provided the such improvarmu.arc.intend d or offered for •• - -
sale.IL lm se er,the Wilding or impovemenl is within ore year or mmpleion.the
idcr will have tW bmUa of proving thus W did not Wild or improve for p r- -
ofsale.).
I.u owner of e. property,,B etionem sely cmBxung Cods:)
od Thedoommon.,m - -
dicl the project( .TO n suet'of and RofeuNm Coon i The es thele, nd _
Sue law das nut y m m owner of property wW Wild-or improvee Illerthv,end -
wW co Rsc pm* wim... orfs)Iiamed portent to tee Conummus
U..
❑lam a,. - ... fa 11(` t]] .
Owner WORKER'S COMPENSATION DECLARATION ' - i AUG �'
(hereby alOrm uMepenury arpcoa of lne fdlawmg daWmom.
❑Ih.a end will Section
of CmunuN nlfinzort far Worome Compen '�,sa y
urian,r pmvtdhi ripe mi Ss imi 3]00 of the IaWr Cads.for the per(oltnena of tW suILi �a
- work eywhich this perms n bribe- - `
❑1 have artl well munlarn Wsukdz Campenwron Iruuruea as requucd by Seagn - " •
3':00 oftb mCode,father peRonwee of the wort fawhirh Nis pemlil i.imW.
.MY Workerses Compemalim Insurance terrier and Policy numbs ort:
' Cartier: Policy No.:
CERTIFICATBOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
' fllussectim WedmtbecomplemdifNe psnutufaoa hurlmed ddlan(3100)
orlon.) -' -
IanifYllulinJe dolmmmoflbewmkforwhich Nizpeiilisiuued,is WI i.
' -
.r nm employ any Penn M any mance,w as to become wbjm,to the Warken'Cmnper- .
satire Lews of California.Due `
Applicant .+.•
NOTICE TO APPLICANT:If,afar making this Ca"Hicere of Exemption,you should'
bembun subject to the Workers Compenasi,,po sjma of the Labor Code,you must
forthwith comply wim such pfovlums m this penut"I W deemed rooked. '
CONS m is.construction
ON LENDING AGENCY
z'� I hercbydEmipelnem isaded(S .30 len ding agemyfonhepefomuece W. r "
z Ne deck for whits this p[rn1il is duties(Ser.7097,Civ.C.) °
tw ti IaMcrs Name
p4 laoaer.,Addrc.. -
aW Q t cmify Nv 1 have read N" IsOut end nese Jut Ne abve infomution is -
7 z mrrt Lla,,aetomepiY with ry c t dimrce sal sure laws nlaling 1.
Wildingcomuserinn,a,d hemE zer mivu osluiscirymaneruponllie -
k. 0id ove-mentionW property for in. n v a.
.(We)agree m save,Inde m'fy maW Ne City of Cupertino ageimt' t '
W iiemoducs,judgmentsetorus#of arts awhich may in mY way eccrve agumt said City
} IAi Ai APPLIC NT Nof the STAN SAN permit
'APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL.NON-POINT
V z SOt1RCEREGUTATIONS. _
I
.. S'll.ofAMlicmt2ouusea D+te ✓Q L ��]� svUGG '`
HAZARDOUS MATERIALS DIS re orhaRC
hedbythel the Cicar or Wforum Wildin8aauyem amrcaMrdle hazudou.INlCd.l Re-roofs -
r u t,sed or Ine CupertinoYfm
Cod"Chim"9.12,and me HWth and Seery
eme.sectienus7z/a)+ Type of Roof
❑YesWill the,pPlicanlar ;ldinear.pm,asee9n;p n,a,dc�ire,which .All roofs shall be inspected prior to any roofing material being
erNl haerdana al,mnarrommtr.e rand by Ne Bay Amur Av Quality Mm.gercnl .installed. If a roof is Installed without first obtaining an inspection
DIB R I
agree to remove all new materials for inspection. Applicant
understands and will comply,wifh all non point source regulations:
1g='=
atimn 25 , 573JamYrcomibiliryIh mel faC ificate cy.- Die nature of Applicant ' _ Date
All roof coverings to+be'Class"B"or better
OFFICE i•