00050025 CITY OF CUPERTINO. - PERMIT No.
'BUILDING DIVISION,k PERMIT BOO NT ' `G I " glad ' 000SQ -
BUILDINGADDRESs:
lti' -SANITARY NO. ' APPLICATION SUBMITTAL DATE
OWNER' NAME' /7� /V//I/'•' .��// _
NIC CONTROL#
ARCHITECTIENGINEHR• /IWN�� {iI/ / ��/ �:, ;U.._ -- • 7�I F
foo '' . •
Z o?3 LICENSED CONTRACTOR S DECLARATION -'
o z-❑ I hereby affirm that I un hccnsed under provisions of Chapter 9(comma ng; Job Description , -
?1m�,•+; with Sanon]00T.dD,Wvon 3 of the Business and Rofmsam Cods6MU .and my lice. i '
?�W Sd'3 'LiTm f r«sadeffect/- ��Jy�ry//J�// //�y may//{' /////,n/ ///s /�////�J1/af/L• �i�iJ//y-,/
u'73va-I" Derc__ 1.
Contrecmr ./�4'/ /�1. � W' Ii/_///V�. (/V "•/V/ • KN/ r-� •f . .
t-.i�O - ARCHITECTS DECLAR
1 understand my plans shall be used as public octads -
i a I:Icenscd professiomW
ct '• OWNER-BUB,DER DECLARATION
C Q 1 hereby affirm that I an exempt from the Contractor's License Law for the _
F C following reamn.(Section]031 3,Business and professions Cade:Any city armory
C which iris a it 0 construct,eller,improve:demolish,or r any etmcturc
a 1C9° Par' Pro ePsi Sq. Ft.Floor Area• Vaua 'on '- -
dMor uu m its issuance,atao rcq.ithe the
ovismsnnt forfthe such pmmit to file.Law(Chaps eat
thed ecingwi ars Secdn700seofDivisim3of eBu&lnms NofLaw(CCWc)w
er 9
(rot he
engwiN station]000)oromiiiofar th alleged
exempt Professions Codc)m AP ND bar Occupancy•fy� e "
' that he is exempt any loll and the saris t subjects
alleged exemption.Any violation of P y '71�
Section]03L3 by any applicant for a pemdt mbjectr the applicant to a civil penalty of
not moa than five hundred dollars($300).'
E]1,as ownet.rthe m.p tori m my mpmyees with wager m th it rnle,nmp n.d.n, Required Inspections
wdl aothe work.dna theawnurc is mot imm�ded.roRered faeate(sec.]004.Buathea .a -
and Professions Code:The Contractors License Law does no apply to an owmrcr of "
property who builds or improves Nercne,sed who does such work himself or through •. -
his own employms.provided tied such improvements we not inteMW in offered far
We.If.however,the building or improvement is sold within one year.(completion.the +
evs.buildee will have the burden of proving that he did not build or imports,for pa- _
I,ro owner of the Property,am cad i.and contracting with:)This dontonc cmrs to
consc -
m.6 La d project(Sec.n an Business and Professions ds or improves;The Cthomon. rad •
came law rices not apply je H owner of property who selids n ttothCommuc and ,who contracts for such projecta with a conlmaor(q licensed pursuant m the Contramrs
License Law. •' .�w . . '
❑1 xe_mptun er Sec. B&PCf rthisamoon /Y
oDna 2/ Zf`/
• WORKER'S COMPENSATIONDECI.ARATION
I hereby aRrm under penalty of perjury one of the following declaations: • ,
Ell heive and will maintain a ConditionofCoosen to aelbd
insu,for Workers Compe !
ration,as provided for by section 3700 of the Labor Code.for the adotm em of the
k permit
for which this is issued.
�ffI have and will maintain Workers Compensation Insurance,as required by Section
E _
cifthe Labor Code, the performance ofthe work for which Nis permit is issaed. • - '
MY Wor yL Fggtp9n y p yx�ay or and Pollry
Carritc k fez )I!/f(L/J�PalicY -
CERTIFICATEOFEXEMPTION FROM WORKERS'.
COMPENSATION INSURANCE 1' •.
..(This a,tion need not be c.mplevd if Ne petmitisfor.nc hundrtd dollars(5100) _
Ricard
Icentry that in the performance ofthe wank for which this perm,is issued,I shed -
nos employ any p,osim m any manner sows m become subject to the WmIme!Compen- '
anti..Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,aper making this Certificate of Exemption,you should
become suitjocuo the Workers Compensation provisions of me Labor Code,you most
'.forthwith comply with sucM1 provisions orthia permit shell be ticemed revoked. - -
CONSTRUCTION LENDING AGENCY
Q, I hereby afEru diet thom is a consbucdon lending agency for the performance of - - -
the wok for which Nis permit is issued(Sec.3097,Civ.C.)
Fy4 Leaders Name
'a > Lender's Address
G3j 1 certify,that 1 be.toad this application and sole Net titillative information is `
Cw cord.l Won to comply with all city and county ordinances ash aur laws relating m' • _
'r7 z building construction,and hereby stalactite reprcrenutives of this city to enter upon the ,
(w) 0above-mentioned proper for ins ",pr",prion,pection o -
L. r. (We)agree to save,indemnify and lute,hnmdeas the City of Cupertino against
0 U liabilities,judgments,costs and expenses which may in any way same against said City _
^tea LL3 in mume9u,nu of the grunting of this panni,. -
' � Del APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-MINT.
V SOURC�±GUL I7ON /� /W " • S 1..
Signature. plicanVC tractor �—
RDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building mcupantrorc or handle hucatd.us material Re-roofs
as def end by the Cupertino Municipal Cal,Chapter 9.12,and the Health end Safety
cede,Section 23132terl`^ i`' Type of Roof
Will Neapplicant.rfmurc building rampart.seeq.ipm nt.raeviceawhich All roofs shall be inspected prior,to any roofing material being
math eardousairconuminantsasdefinedbytheB4ArctAirQualityManagement installed. If a roof is Installed without first'obtalrimg an'inspectlon
I agree to remove all new,materials for inspection. Applicant
r ❑Yes r1/'N. - g p pp
- �hawercWNehaiarduu'mearuts mcquuementeuMerCMp1n693ofdaCili- understands and-will comply with all non point source regulations.
forme Health&Safety Coag Sections t,to,i 25533 es 25334.1 aMnstand that if de �/at
building d,enmcarently pass to uam.that it ixmyto of.Cility to cate,yOme.ccmpani
s ,, of 0c^uirementa Run he mmit prig m ivuemmce of a Cenificm< upenc �y -
oww,frac •,era - .m Signature ofAppli ' - Date
,w X11 roof coverings to be Class"B"or better;:
' " OFFICE. . .•,. -