00020179 CITY OF CUPERTINO PeRMIT No.
BUILDING DMSION PERMIT CONTRACTOR INFORMATION: b it r, f'-�•-�
BUILDING ADDRESS'. 'ea. `1t l/ d�•lJ
�LH Tll� SANITARYNO. APPLICATTONSUBMITTALDATE
10793
OWNER'S NAME: 'p
I"A ILj�— t]�A tJT NIC C01 OLg
PHOIIN^^C: - Cl
ANC��IIII'Itch'/eNGINEER� - RULDINO PERMIT INFO
,O \
O I�VtfV l��
OF
y 66
Z O = LICENSED CONTRACTOR'S DECLARATION
O z_ I hertpy affum WI I w licensed]under provisions of Chapter 9(communing Job Description
F:t-u� wish
in Nil foram and SoriBund fofDivixian7ofte BuaiwaaM Prof�sim Cade.md mYlianu is
=.m< effect.
K Lies.0. Li[.N ��`^'•""` ` ' ts'1 P^1IQ����
y 3 u.y DOU Contractor
wCgARCHITECTS DECLARATION Amt_ O -)e
a1 understand my plans shall be used as public income
i d° uren.ed eroreasiow SOl•k•3 e 7.�nr�'r"F 10 h
_y OUIIDEfr DECLARATION
X a I hereby effw the,
I mo em exempt from On Con[nctara Licca taw for the
TTS c. E followwhich
gnues a(Section co L5,Bualaas and improve,
casione Cade:Any city Or county
3F�m which rtquina n pewit recentrum,alter,improve,demolish,or repair any swrnsrt Sq. Ft. Floor Area Valuation
pdwmiu issuance,also rtquim the applicant for such permit in rile seined aummcm I I S'O p O
ten he ie licemed pwsuant tote provisiwa of Ne Cweacmry Liana law(Ch.pw 9 U
(commencingwitSadon7")9foitisia,3ofineBuaine.ee Nofeuinmcad[Iw ApN Nb
Oat he is eump[duc efrom and the basis for that allegW Number Occupancy exemption.Any visitation of P Y Type
Section 7031.5 by my applicant for.pemdt.0 s*ta te.ppliesm to a civil penalty or Z 3M—
n mart Nen F,Without dollen(53001.
run
I,ason aftc propcnYwmywpltyru w offwmlfor We,nme Sas.compematian, ��� 3 oO Required Inspections
will doolework sedto he Connisnesa UMem Law diosnora(Sec.o W,BusinessRequired
and propPooerty
ho Code:The Connector theme.
and!w Caw secs nes apply toanavnel o/
progeny who build.primped that
tenon,acro who does mch ante sed or
or through
for
his own however.
On provided Tho such impmamenu art nes intended o offered for - -
.me.If,howea¢to have
ting w en of proving
at h did withinme Wild
or improve
foo•to ,.
ilder will have TM1C burden of proving tet he did not build sir improve far pur-
pose este.).
ower of to Sm.704,B eaess and cwnwith licensed con asses i-
construct to Project(Sm.7044,Business and professions,whicbl Come.The Cwtrumb Li-
who law does nm apply e t,owner of property who seilm+w improves Thereon,ems
who contracts for each projau wit a conmctoH0licmUm punuw to to Canbectm s /7L'
IICCn {aW.
w /
[]1 nxemPT under Sec. .B k P C for this reasw �/
�i
Owner- -� Oma 0t7
WORKER'S CDMPENSATP y€ RATION
I hereby elfiw under prnelry of perjury Mo!The following dalanuwn:
-t1have stdwilll Nei b Swum
37 tc of Csimem To Coin,forthe erforma Comf the
lion,es hick the pe ni Ss imu 7)00 of to Labor Code,la the penfomuwe of the
wmk for which Nla pewit is issued. '
❑1 have and will mainla r WorYars arae often w Imumna,as rtquiM by Section _
My orl eLabor Code,rw Theprrrwmawe for ars: wit is issued. -
My Carrier:
Compensation Insurance coma unit Policy number w:
Carets.: Policy
CERTQ'ICATEOFEKPAIPTIONFRO WORKERS' -
COMPENSATION INSURANCE
(TTie xa[inn aero rad becompleled ifte pewit is for oahuTTAetl dollen(5100)
Or lues)
Icenify Matin The performance o work for which Ni.permit "I
ma employ any pnaon in any men m co pcwme aubm o tto Workers'Compn-
wipLaw.of Celifomig Dau
Applic
w
NOTI
NOTICE TO j APo the WoI:If,toter making this Certificate of exemption,you should
hecome subject to W such
pro Comsenutii,permit
to Labor Cade,you mon
forthwith empty wit such provisions or tis pewit Mell be demand revoked.
CONSTRUCTION LENDING AGENCY
Q 0 I heuby affirm tat Cert is a construction on lending agency for the perfonor
On work for which ON permit is issued(See.TNT.Civ.Q
Ey Lender'.Name '
1<Mc
I mrsify
(I: cenify tat I have sued thirty end coup y m awe Thar TM above ors relation is
IY corning I ensue ic comply with all city end county odfives of and amu laws suwin the r^1 Z abrovengcomwc propmt hertbyauThon urpose.. ivea of this cirymenter upon to
V above-we)-S peopm.undearnify an Onep hu.
Lr, (We).greemeaves indemnifyendkap hay in m They CityOf
against id City
W incomea,judgTf theconaM nOur permit. may in enY wry ammee6ainn aid City
} W iAPPLICANI NThe STAN of This pewit.
F SOURCANI'ULATIOTANDS AND WILL COMPLY WITf1A1.L NON-PoINT
U z SOIIRCE REGULATIONS.
igneture of AppbcwVCOrftcto, Date
HAZARDOUS MAT AIS DISCLOSURE
Will to applicant or future Wilding occupant store or handle hanodoua material Re-roofs
as defined by The Cupertino Municipal Cade.Chapter 9.12.eW the Hedt and Safely
Code,Swum 2557x.). Type of Roof
❑Yes ON.
Will rhe epplicaet or future Wilding occupant use ap0moem m deAcex which All roofs shall be inspected prior to any roofing material being
emit hazudws air conumivnTs as deOnW by to Bay Aum AG Quality Managemem installed. If a roof is Installed without first obtaining an inspection
ra ❑
" " Yea 0 N I a ree to remove all new materials for inspection. Applicant
I
have read"n
ham"i melenala¢quirtmems tracer Charier 695 a to Cali. un erstands and will comply with all non point source regulations.
forms Health g:Safety Code.Sections 25%5,25533 end]5574.1 uTdenwtl to if the
Fuileing doe.ma currently have a ten.m,tat it is my responeibiliry,to bad,to occupenT
of Ter(ylgmemhich m t mm prior m iasutae of a Cenificem MOccupency. ,
fVb 1 1s Signature of Applicant Date
mer or eudwrized.gem Dan
All roof coverings to be Class"B'•or better
OFFICE
T313
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