00020144 CITY OF CUPERTINO - r' - PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
WILDING ADDRESS: '
{01x•/1 1 SANl1ARYNO. API'LICATI°NSUBMITTALDATE
.
:WC CONTROL.
_ •_ ❑
ARCHITCCTIENGINEER - BULDING PERMM'INFO
r LICENSED CONTRACTOR'S DECLARATION •, 1 T, : .
._Z= I hereby afftm Nai l am licwsed under provisions of Chapter 9(commencing - ,. Job Description
with Section]000)ofDivision 3o1'Ne Business and Professions Code,.Many license is (/1'�] (� /'.
Lacer Tome.-ellen. N�vv '"' WogrtJl ��
—ye'r V In«nu Class - Lie.» x1 v v
3 Date Connacbr
t_ O ARCHITECTS DECLARATION ,
'^g I undestmd my plans rM1etl be used as PuM1lic records. � 't• .' � /" s4
Do K •
a q R N Licensed Pm essimW
u�7 OWNER-BUILDER DECLARATION
1 hereby affirm that l am exempt from Ne Combacon's License law for the
O fallowing reason.(Section]031.3.Business and Professions Cade:Any city m county
which nquirct a permit an courant,emr,improve,demolish,or=pair any structure
1 t nuance,also res Nee 1 tfor such Payout Man ri edam=mem Sq. F(. F'�QOr rex ^ 'V�atl9tl
prior of its =qui pp icon acme ga (Js� L r(GJllt
that he im.mi,aM pSeeuanuod)proviviom of dx Conull. Licenu law(Cbepa9 1 y
(hammwemgwith becdan]Oo0)o( basisfr ofthe
egenexrmen.Anym,.cax)m PN Number - Oceu 'ane e
that he is Bump thrnfrom and the burs for the cttCged exunpnan.Any violation of A �, I Y Typ
not mo than by anyapplicantdui for a permit subjects dm applinnt to a civil penalty Of `/C!/1
not mom than Bft hundred dollar y employees
❑Lazowner ofinepropenr,rr myrm truscee:wiN wages utheir(Sm.compensation, - - Requiredlnspections'
will donfe wmk;aMthe structure mom imm�dedLaw dos.1 apply a1an Businessrof -
iio arty who
Code:]be Consaaorr License law docs nal apply s if sumer of
property whooyees,pr impova Nowa,and who dans on work himself f through -
. his own employees,provided WI such impmvemens e=nm intended m offered nor
sale.w hMewethe buildingorimpovemwlhinh did noneildori ompe for Ne
_ nbuiWer will hare Ne buNcn of proving that he did not build or improve for pry- t
ovule.). �.
` ower of Its,propcny,am exclusively contracting witb licensed,morecton m AUG
1 a. O 12001
• q O O�
ns u I Ne project Businsu aM Rofeuions CodeO The Conuxmh Li- H�/U L
anti taw dues not ly towowo«ofproperty Who...Maor)Tbacedme.e end
who confine c pmjauwsursuem
ith. mo.)licensed puno .he Comsat '
Liceno
u I -
❑,tam .BkP Nice7 BUILDING .'
Owner " `
WORKER'S COMPENSATION DF.CLSMTIO r N / -
-have
and will
undo pwalry of of Caremm of dm froure,or d orlm's u:
❑Ihevc and Provided
delorby eCion 370cam of Continua Cadself,far the Performance
,.
ration;four which this
for mi Section 7]00 of Ne Labor Code,for Na performance of 1M1e
i workhave
which ill permit is issued. •�
I have end will ode,fon WaNclr Compensation Insurance.which
h his Permit
bySection
My ottur',Co CodafonNsurance canttof Newark forwhich Nis permilui.wed. ..
Centaur:
Compensation lnsurwttcaninwdPoliry number tie:
Carrier. PNY Na.:
CERTDIC OF EXEMPTION FROM WORKERS' -
`•
COMPENSATION INSURANCE .I
(This awtinn random be completed if Ne pamil iA rorone hundineddollus(SI W)
I cenlfy dnl in the Ir formmceofthe Wank farwhich Niapemel is issued,l shall
+ nm employ any person in any rnenrcr w u m becrnm mbjat in the Wmken'Camper. - -
Minn law.of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should - a
become subject b the Worker.Compensation provisions of Ne Lidam Cade,you muss
voMwa comply with such provisions or this permit.hell be domed revoked. - -
.O Q _ CONSTRUCTION LENDING AGENCY -
s Ihertbyo ,.Nn Ne=i.aconsandonlendingagencyfmlheperfom ceof , - -
Z•2 Ne work for which this permit is timed(Sec.3(aO Civ.C.)Under,Name .
Y.a Lend Addrc s - -
L*� 1 can fy def 1 base rend des i Tic Don ed m Net Ne abr sur rmnion is , -
5 z conal 1 gree to comply with ell,a+ our gL��n I and rut le =leafingm
U O 'buildng construction,and hereby au+weu sup utrya oflN 'tyt urupon Ne
above-mentioned popertY fm inFec4an purpmer.
fi f~ (We)agree to aave-indemnify and keep harmless the C it,of Cupertino against
U Iiebilities,ludgments,costs and expenses which may in any way scrao,Usual said City
^>a W in consequence of de granting of Nis pemtil.
F- d APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-MINT
U z SOURCERLGULATIONS. ' -
rn SignSignatureof ApplicacoContmam e Dem �� L.. /•`-'/`-7O�k/ Car
i - HAZARDOUS MATERIALS DISCLOSURE
WillNmpplicent or fuwm hilding acupantsm=or haMle hazeNous ro m id Re-roofs '
as defined by Ne Cupertino ry�����uyyy��dpww.I Coda Chapn 9.12,ab Ne HWN end Safety - a
Cade.Section235320,)? - Type of Roof
❑Yes
Will the apptinenlOrfawmNoldiagacupantu9eegaipmwtordevicexwhich
All roofs shall be inspected prior to any roofing material being
omit It exaou9 aiulla
defined by the Be,Arca Air Quality Mebigemcnt installed. If a roof is Installed without first.obtaining an inspection
°``°"'] I a nee to remove all new materials for inspection. ,Applicant
Yes g
b.aeinma i- understands and`will comply with all non point source regulations.
foe61N ns 30,23373 end 23334.I un un0 Nm ifNea itiunyu.9pnnsibilityt ifY Ne =pantm1 (,'wlfi (k'-
ignature of Applicant Date
Owaermeu nz agent Dam � '
A11 roof coverings to be Class•'B"or better
OFFICE