00040103 CITY OF CUPERTINO PERNUTNO.
BUILDING DIVISION PERMI CONTRACTOR INFORMATION:
BUILDING ADDRESS:. , 1 -,— `^/ "V I O
` Wq 1� I�(„LG ^ 00 11 SANI'TARYNO. APPLICATIONSUBM[TTALDATE
r uwNER'.IjNAME: ` ` Ner 1.\t2'•. ' �Ly-istY0o ..
1` t4A9 _ ` �� ` �5" NIC CONTROLp
11 DNC. . ,VIN IV—�•\�N:/3V'7�7
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ARCHI.FECUENGINEEReco a A 1 C .` �903� _ BULDMO PERM IT WF0•TO \ \ t \ r l..( . .
s-D zLICENSED CONTRACTOR'S DECLARATION "
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:— I hereby aRrm Nat i w hcemed under provisions of Chapter 9(co wong Job Descr p •on ...
m l—uq{ with5ectior'I"Ut' 1v 3ofdo BmL'euand Dofesai...C .and my lictnxis � '
— in full force and eRecL - ,�. Q���PQ'nso B 0.6 c)K t �� ! .l - ;
z res < LieenxC ' Connector 4)<ivc •� �//� V`g{ �yy `y� �a�(I� o VA\l1 ,'TN
O g Dem�CTS DECLARATION ��`�/ �C, 0 r� �l
2 iundertand mY Plans shall be uredo public records lt^ 1 .etQ\I r
W
S c ticrosed Prohu;onal - s - .
OWNER-BUILDER m Ce Cont,ON t ..
?G f heasorereby a(Sect Net 1 em meant from the Dations Co :Any c Lew for sty '
O whichhe
Thdowingmassa.(Stolon 7031.5.construct,
t,altar, and Prolusions Code:Any citymroomy - a
which mgnircsae.and torerirei gaLorae,,impmve,dmm.Rm,fie a sig MY structure - Sq. Ft.Floor Area c - :Valuation
pnmmits issuance,also rtquims the applinmfor such pmmit wfileasigned.uamem D '
that he is liurved pumuanno Ne proviilonr of tree Contaanofa Liccno Law(Chapler9
.(csmmencin6 with Section 1000)of Division J ofthe Busineu and ProkuionsCddm
that he is tamale therefrom and the basis far the alleged cxeaptiha.Any violation of 1 -APN Number. ' Occupancy,Type
Section 1031.5 by any applicam Bar.pc md,mbjects do applicasns a civil penalty of ��O3
not more then rive hundred dollars(531101. lJ
/ ❑ dothe work,and
thesum ,mmrot moyee.muwagesu theirwle 01finacing Required"Inspections
will do Ne work,end NeaWcwrcis not intended muttered!foresee(SaAMa,Bueineis - _ q, .T..
and Rofutiom Cade:The Conuaeeor's Liana law door not apply to an owner of ' ...
prope,ny who builds or improves ehercns,and who does such work himxlf or thorough
his own employee.;Provided that such improvemeab ase nm intended ver offered for
tile.If,however,tic building.,improvemrn,is sold within one ycor.f mmpledon,that,
owrr<obudder will have the burden of Proving that he did not build or impmve for Per. t� n p es tsv® -
❑I,u owner of the papery,,B cxdu mal co Fexdmw with:)entad tom)mon to
c.nswct the project"n,to 4e.,omer mr and Rofeul builds
The Conuecmi s U. s - - -
cenx law door not apply w an owns of palmy who hurlers m improves down,end t ',:'?JUL
.? I I I I O-7 0006
wicembe INs for projata wi nVaemlfs)liubaed purswnewthe Conbnn.fs + JJC L .
Lieenss law.
_ WOR R'S COM NSATION DECLARATION
I hereby mif rm under Pendry of perjury one of the following declared.
s.,
]Ihpvc atMwill for bynaCe+ifcetc of Cansenno xlRinsurt for WoheM1 Compen-. + '
pion,es provided for by Swed.,3100 of the Labor Code,for the peiformatwe of the •
ojk for which,hia peau,issued.• '
y 1 have and will maintain Weal Compensation Imurabom w Iryuhed by Section
ofthe Taboo Code,f.,theimarm,camor and al ek for which thio permituisauN, s""//�'��+.��• -
MYWs sCompcn 'on lnsurancc ramp end Policy he
Camcr. PoIicY No..E -
RTIFI- TE OF EXEMPTION FROM WORKERS'
- ' COMPENSATION INSURANCE -
(This smooth need not becomplmed Blue peadt is throne hundred dollars($1f10) AP 18
2000 -
Icmify dutin the perfosswu<move work for whichthis permit isiuued,]shall
not employ any pecan in any manner x as to become subject to the,WorkerCompen- -
ration Laws of Califomia.Data ry
Applicant y 1
NCTICE,TO APPLICANT:IL after modung this Certificate of Exemoma,You should
hecome subject 1;Ne Workers Compensation Provisions of Ne labor Code,you must
fonhwitlecomply with such provision.a this permit shall be deemed revoked. '
CONSTRUCTION LENDING AGENCY
Oro IhercbY'dEtm dot there isacomweuon lending aemcy far erre pertsmwee of
z,to Ne work fm which this permit is issued(Sec.3091.Civ.CJ ,
E., Lender's Name -
�+ lenders Address
far Q 'I realty that 1 have cad this application and sues that the shave information is - _
z co
rrect.l'agree to comply with ell city end roomy ordinances and sur haws relating I - -
building mermo Den,and hereby mnimmir<represenwrives of this city to enol upas the
C.7 above-memionedproperty for inspection purponc,
(We)term to save,indemnify and keep humleas the City of Cupanino agdme
U liabilities,judgments,costa and expenses which may in any way accrue sibilant said City _
} W in conn'wermc of the grmiag of this permit
fti APPLICANT UNDERBT YD. Ap WILLCOMPLY Wfril ALL NON-POINT
f..) z E ULATION�S. 1yy11� - _ . -
\IA� -1gj'-E» t
1`
Si rem ApPlicanV nvacL� tom Due s -
HAZARDOUS MATERIALS DISCLOSURE
Will thcapplican,orin,..building escapist,stom.,handle hawdous nurcriel Re-roofs
as defined by the Cupertino Municipal Cale.Clommor 9.12,and the Hedth and Safety
Cade,Seetion 25532(e)1 Type of Roof r
Will the applicant or future building occupect use equipment or devices which All roofs shall be inspected prior to any roofing material being
not Itaados uair conummmr u deR by the Bay Arta Air Quality hLnagmtene installed. If a roof is Installed without first obtaining an inspecti
non
I agree to remove all Lmp�l�
terials for inspection. Applicant
❑Yrs o d
I have rand the harardows materials scyuimmentxunder Chapter 6.95 of the,Cali- Un er$tandS.a wi,l' with all non_point souree,regulations.
foau Hcelth&Safety C Secf s 2 505,5533 and MIX I understand that if A
building does std currentl.yQAfsv\cat m in d"mYtapmdnilitywnmify gas occupm'
�ma�rynenz w kh mus\be t wmiasuenc ofaCeni,1- (e(/
!_7M{e iJ fkAJ\ Signature of Applicant Date
` Ow m.0 o edagcon Date
All roof coverings to be Class"B"or better
OFFICE;
CITY OF CUPERTINO /a'; {`_� Y"off' 1 "1' " �*y `"'�#* ��T += PERMIT NO
P BUILDING DIVISION PFiRr .«,T €gtrTl. 00lFAYI 'rw
t t ii;.k 4CGfikW E• } .rksb.44..t€ v,i��(., �—t L. L,•
7 BUILDINGADDRESS 1 I•�
4�I wry• + tail ( I �1 p•.� /� SANITARYNO APPLICATION SUBMI'PLALDAT
. 1 f t r 4 A L.0
OWNERSNAME: ... I. Ji + Q1 t"'{�1 LM� f.4
N/C ,COMPROLOROL#
b't 1,
ONE/ r + — ❑
ARCHITECT NGINEER J { 0 MtT l ',:TuLDINo PlufMrrlN[+o,
y< NOTES
Z Job Description
Yti. .... ,.Jt:,:.,. �LI r1,� + •.,
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Sq. Ft. Floor Area Valuation
APN Numberr+ 'Occupancy Type
Required Inspections
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Re-roofs
Type of Roof
All roofs shall be inspected prior to any roofing, material being
installed. If a roof is installed without first obtaining an inspection
I agree.to remove all new materials for inspection. Applicant
understands and.wilj. c mply with all non point source regulations.
Signature of Applicant Date
All roof coverings to be Class `B"or better
APPLICANT'S'POSTING COPY