00020136 CITY OF CUPERTINO ' PERMrrt4o.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUIhDING ADDRESS: SANITARY NO, APPLICATION SOBMTITA ATE
iso erg Bi -
O NER'S AMI?: . 1 ° lO y NIC, - - CONTROU#
:CHITHCT/HNGINEFR' BOLDING PERMIT INFO
he
z�„� Inerebr.R LmCi theSl un lOiacmedunderR pmn'sCinm of CMpser9tcammemmg `�• - 'Job Description -
�coFs'Cu with Sectim It WDlvlslon 3 ofdx Business”PmfeWoru Catle,W my Harms is
�
L
ceicfire.
e roClm "
Dan,.
- Lm.g
. 1 �`.N�/ V V 1 \V./�`•'1 `�1"V+g\v
3 y; Date - Contractor
7rS DECL DECLy. I,
t LL O J ARCHITECTS ARATION
y - 1 unstntsM mY plena shell be used u public meads
a�j e Licensed Profeeeinml . l
OWNER-BUILDER DECLARATION r a
C Z a ♦ 1 hereby rafters that 1 and exam,,from Ne Comranofs License Lew for the .
O following mason.(Section 9031.5.Business W Professions Cast:Any city or count
m which regaima.permit in co mutt,eller.improve,demo fish,o:repair my saagtum . " .Sq. Floor Area - Valuation.
prior to its issuance,also ruptures dr,applicants,faoucb pemth m file a signed ststemcm
Notheislicensedpur ttoshepmvuimn of Ne Cmawt&sLi<enulaw(CMpter9 '
000
Icommendngwi,h Secdon]00(yofgidRlon 3 o dse BudiessWProfessi aeade)a APp� ��umber Occu a c Type
'
Nat be is eutnps therefrom W she basis far the alleged eeemp,im.A,violation of /•�Y�,�� p Y Yp
Section 1031.5 by any applicant for a permit subjects the application a civil pemity,of ,,NGJ ._ u
pt mom Nan five hundmd dallam(95W 1.' - XJ
has aw,kr ar the property..my empiayeae with w.gea..duo-.oie compenvdm, ,Required Inspections
., will do the work,and thcsvvcmm is nm lmmrded or offered fm We(Sec.J044,Rumness
and Profusions Conk:The Comrac,a's License law coast era apply,o an-mmer or -
property,who builds or improves thcreoq and who does such wod himself or through
his own employees,provided she,such ImpmJemants are not intended or oRaud for
We.If.however.,hc building or improvement is cold within one year of completion,she ..
-builder will base rM thNen of proving du,he did and Wild or improve for pear
Msales).
r of el property,am Bothnia
coumecring with licensed conuaour. to
c m u cone a,sur (See 9(144,Business e,M Pmfesslom Codes Tho Conmecmr's Li- ,•- 't w•lyp' ,
<erue law tines nut aP9qto en owns of property who W rids or improvea tMmoh,end fA tt�Iu' ' ,
who eanaans sec lata wish a conuactor(s)licansed pununua the ceremo ",Let me Law '"�
' ❑lane cx sip, a - ,B& far Ni _ - . �g• 1 e .
p l? 1
WORKER'S COMPEN rjury W DECLfRAT10N D1� -
1 hand will mai under penury of mpvjoy one of the following dela es Cropper.
I have and will fee by Se Cions 37M of
ao inaurt for Workme Compeere
,ion,for-
provided for by Section t, of Ne Labor Code,for performance of me
ak fa,and thispnitmin issued. r '
' ❑I have W will malmain Workers anceo thew Waracce.which
h required by Sssued.
My Wicker's
Cio Cost,forteperfon cmir,mcl work fWmWh hshit permit is issued.. . . .
My e': Compmu,idn Insurance cetncnnd Policy number ere:
Camicr: � Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS" -
COMPENSATIONINSUIUNCE - -
(This section need not W completed ifthc permit is rorme hunhnl dollars($100)
or less.) {.;• . �
Toy my moa the my
Winner of shewakfar which thio,amu,isers'Co pan- -
'no,employ any Caron in any menrcr co u m hwme subject m Nc Warken'Comp<n- ' -
actAfsphLaws of California.Date
Applicant ' ', •.• '. e - !.
NOTICE TO APPLICANT:If,after meting this Cc iOcne of Exemption,you should •d
become subject m the Woheh Compenution,Durston&of the Labor Cade,you mus,
forthwith comply with such provisions or this panni,shell W deemed invoked.
CONSTRUCTION LENDING AGENCY -
Iherebyaffinn shot then is a construction lending agency forte performance of -
z N dm work for which this permit is issued IS c.3091, iv.C.)
a ,.y Lander's Name '
.} I.sidnei Address ice n ' -
L:: 1 certify Thal 1 have reed thea Rry el the about infomu,ion is 4
Gr Q correct.I agree to comply whh all ci my N s W sum laws rilium,1. r
U O buildingeonstmcdogendherebyau num esoftlusci,ymenmrupon,he
'above-mentioned property fa inspmtion purpous.n
R. Fy (We)agree in save,indemnify and keep have less she City of Cupertino egalnat
V Imbililies,judgmen,s.costs and expenses which may in my way accrue against said City
-2c/7)
Li: ,
} in consequent.of she gmming of this p .
.Fi % APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT
:.3 SOURCE REGULATIONS a
-
SiBn+mreofAppliaan✓Comracla ' Date
IIAZAR W LS US MATERIADISCLOSURE
Will the appli,sema,fumrc Wilding oecupu,nae ar handle hoards.material Re-roofs
as def sed by,he Cupertinn Muni n CNet Chapter Y.12,W the Health and Safety
Calc,Sc Yes 25532(e)? Type of Roof
Yes
Will the appli, fa,am kill ingocaapsn,are egalpmem o,devices which .All-roofs shall be inspected prior to any roofing material'being.
emit htoardoua si,ocrabrimnts fined by the Bay Arcs Air Quality Management installed. if a roof is'mstalled without first obtaining an.in'speetlon
District?
I agree to remove all new materials for inspection. Applicant,
❑r« ' g
Lh.ve rheh smamHas,eyairtm ms.'aerEh. r6D5afdcCali- understands and will comply with all non point source regulations._
forma Bealth Safety ecmrs 25 5 5533 W 25534.1 a led Nat if the " f•' -
Whiingdoes acomen a morns. Smy rmpomibili , neti(Y ampent - -
of the raga a whl f Cert Luo
Signature of Applicant
Ownermitwhorieedagem Date- au - y -
` I All'roof coberings to be Class"B"or better
OFFICE