00030157 yCITY OF CUPERTINO' � - � PERMTTNO.
HUSDING DIVISION PERMIT' . ° " T s R INFORrM g s(''F
BUILDINGADDR MIN)
rVO �Ol71� ^/ - ,�'� � ,, SANITARY NO. APPLICATION SUBMITTAL DATEOWNER'S NAME �+(, f'W� ^/ N/C CONTROLLa
" ,ARCHITECT/ENGINEER'
' mm // 12A 5a!
z_ ^ LICENSED CONTRACTORS DECLARATION Clht�L!' / /r'Ns�. I//"L✓'�'S'�"•�^-6- //.�
y„a r nereb h m mat l.m hrrn nd mneer lob Description
Y e pd ftfess of Chapter 9 my limnrc
i.,4C, withsectim9000)a n3of the Busine¢s and Profenions Cade,end mylittnu is /, ov
y , in Poll fneH1:'t.�'1 /L rVi.I sfG. .. 'N,t.Ir;mss. PS-
Liven¢ diff
�hy`.r_'-�_LIC.M— �1
T'S DECL
DECL
ARCHITECT'SARATION "7_/
�p-� 1 understood mall tend mY Plans l outl u records
records� MS` -••/�(OLG/'S 4.L.T '
Licensed
OWNER-BUB.DER m the Con ION u
C 3 G •_f hemby ahmt m I am exempt from the femm ors Luene Lew fm[he
3'O follow %rumn (section"10315,Bussn<ss e,W RoRwou Curie.AnY CnY or co my �• �� - t /
� which req ties a permit to corevucl alter,improve,demolish,eneop.v any moron m -
limmt .n m.4.".im,theapplica'tf mchpermltWlik.,lgnedsta¢ ent Sq.-FL•FloorArea Va anon
that he licensed Poemant to W provisions of the Connacmis License Law(Chalsor 9,
(come,neingwi"eOon7X )of Division3ofore Businasmd ProfessionsCM)or _
Wt be is exempt therefrom and the basis for me alleged exemption.Any ululation of 'APNNumber .. Oce nay Type .
Section 9031'.5 by my applicant for a pemtiuubjeets the applicant to a civil parmy of r -
not tiwri Nan fve hundred dollars($500). - '
❑1,aeowneroftheproperiy,mmyemployeeswimweguutheirmlerompenuion; `
Require(—jI1(speetions - . .
and do Runwork,andi;The Coamw mint t...La cloys not apply tod4,wrier a _ i
and who
Cali The Con,ncmr s.and w law dine not apply m lf owner gh -his
owproperty employees,
ldses,or tmprovu t such improvements who does such work himself or through -
Wa own employeese Provided met rov ssoldw art not mteMed a offered for
We.lL however w the have
lding the burden
is at N,dici m, yeazofmmpleuon me p - -
owneof We.).
ewill have me burden of proving that he and ant Budd or improve far put -
E]1.a salE.) jl t.
❑1 u t the of me Property ,Business
ly c helmong with licensed contractors;toemi -
Li-
immLa cl Pro)ea(sec,toys,owner
op rry who bur Code)36e es the ton,and
who coawdmorsuchapply mmoith aommustosry whosedpds orimptovu maeogand
who mnLaw. such projecu wimeconuacmr(a)li<enxd pursuantmthe ConVecmre
License Law.
❑I an exempt under Sec. Bk P C for mism. s', .r ,
Owna' Date
, „ r
._ WORKER'S COMPENSATION DECLARATION' • ,.
"1 hereby+VErm under pcmlly of pvjury oma of the following deelmnion: o-
I have aM will rnainWn aCmiocak ofCon,.t t..l6insum for Workers Comp n- _
setion.as provided for by section 37M of the Labor Code,for the pesfosmanpe of me
which lis permit isomed. _
1 have and will maintain Workers Compensation luminance,u requited by Section
of the labor Code,for the performance of the work for which this permit is issued. _
MY W ala Com en aImimaece ca and Policy n • - -
Camer. Olay No,: - - - '
�1•Y,C�' CERT CATS"EXEMPTIONFRO ORKERS' n -
COMPENSATIONINSURANCEt ,
(This wilm need non Wcompleted Rine permit is forone hundred dollms(5100)
IvanifYmmineieperforr me ofihewmkforwhichmispermilisissued,Ish4I
not employ any person in any manlier m u ro bewme.unect to use Workers'Compcn -
Winn Lows of California.Data
Applicant
NOTICE TO APPLICANT:If,after making mi;Certificate of Exemption,you should , r -
become sub e&to me Workers Compensation x•
I es provisions of me Labe Cade,you must
' forthwith comply with such provision or this permit shall be domed revoked. i : �..` •' s ,
• CONSTRUCTION LENDING AGENCY
O Q I hereby short thout them is a construction lending agency forthancifintremsef `s
r•w me weak for which Inst perms isi nmed 3097.Civ,C.)
Fy Vi .Lenders Name - t _ 1../ • .
-[� �5, Lender s Address ll�l
Iffl qI
W A 1 terrify rho I have tied N. pplit coon and nue that m bo a information. Mile,is - LIAR `
d builder 1 agree to comply with all city d county ordi,es of and me laws,upon
e, ♦O000
r� z bWv..gm,ioad iogand htt inspecby tion purposes.
Ives ofm's city to enur upon le .e s L
C.7 O bovememmned property for mapecuon Puryoses - % . . . '
Loa Fy •�(We)agree to save,indemnify and keep harmless the City of Cupertino agaftsi
O V- liabilities judgments,costs and expenses which tory many way accrue agaon mid City d 13y `
'n coosegvence of the granting of this petmm
_F 1a APPLICANT UNDERSTANDS AND WILL COMPLYW ALI NON-POINT _ �"'^�.... �• 1
CE REOULATI NS.' '• , • f+.1
Sigumre of ApplicmVCmn Deo -
' FIAZARDOUS MATERIALS DISCL URC;�'
.Will tbeapplieant of future building rccupam store or handle hazardous material Re-roofs
as,cfined by the Cupertino Municipal Code,Chapter 9.12,orad to Health and safety
Code,seeds.2S5320D2 I
[]Ycs 0N Type of Roof
r ^ s • •.
Will the applicant of future building neupent use equip mor devices which All roofs shall'be inspected prior to anyy,roofing material being
uw w
-•is hardous conninmts as defined by the Bay Area An Quarry Management installed: If a roof is Installed without first obtaining an inspectioni
let?40 ❑Yes. ❑Na I agree to remove:all new materials for inspection': Applicant'
agree
un erstands,and will co ' ly,wiih all non point source regulation's.
1 ha a reed me hazudms materials rtgm menta d Chapta 6 9S f the Cali- •a,•
funds Health A,Safety Cade,Sections 25505 25533 ad 2553a I tonakramd mat if the , .f •r
building does noicumeOY havestenant,that its my pun b'liry m notify the rccum
pas ,�t���/q � •.
of the ley " ra n mm�t be met poor m' encs of.
Certf ta fOccmPencr.
Igna ure of Applic t - ' Date _ -
Owneraraummnzedagent {' loci:_, -
Al]roof coverings to be Class"B••or better
OFFICE
VOW F - MAR 2 4 2000
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BRAND KITCHEN BRANDD Ro*1 February10, 2000