00050057 ' CITY OF
' CUPERTINO PERMIT dNO..
PERMIT
BUILDING
BUIL DING ADDREC_
J
':
may' SANITARY NO. .p APPLICATION SUBMITTAL DATE
Y OWNER'S NAME YwJ a:., - /� c �t /J " �c
J I. .P/GZL.•/17� / - N/C "CONTROL M
ARCHITECT/ENGINEER" - , 4,. r� i • B•' _ -N (] .
wUZE
.,o y i LICENSED CONTRACTORS DECLARATION
OZ=1❑ I hereby million that I un Bayed under provisions of Chapter 9(cosiimeiemg l Job Desenption
P¢
4t. with Section](,()O of D' situ 3 ofthe,B,umax,and lumfoutimis Cut an,he
mow . in full fcan.orce and.Rept / / 4
Co.
ARCHrr i( DECLARATI ..
1 demand my plans shall be axed as Public rcroNs . 9 a '
Prvf
oimal -C
-a • r OWNERrBUILDER DECLARATION '+
.I hereby&Rim that I.am exempt from the Connector's License Low for the
,�EM foilowtng«ason (Sem 70315 Business and linelf mnv Cade Any city w county
m $ wnm t regwms a perm t m wet,epic tmfor m Jemmltit t orFile.sir any amiane ,. - - b
d� its - L Floor Area - Valuation
,
pdwtisli un n.,ahoy.quima Mvisiocantforsun=metLiemm gm(Ch est
Ihmhetrm.gwi pumumfao th)mfDivNmof Ne CmnmackYa LtceidaWma Cada)., .. '
(month mempt unefir ](100)di basil for
rofNeeged xs ipt Pr"Any vi Cade)or
Section
31.5 b mertfrom and the beim for the alleged ppl an Any violation nr ',t .'APN Number Occupancy Type
Serf n 1031 S by any applicant fora()bonsai subjects the applicant to a nes penalty V
• m mole man five hundred dollen($3W).
C]1,as owner ofine property.in my employees with wages as theiriole compensation, -�--- -Required Inspecticl - v .
will dome work atW meaWckrcta trot mmndedoroRered
for
We(Sec. .Business
and Pmfesatons Code.The Contractors License taw does or ePWY ro co owner of •-'^" _ --
proparty who builds or improves therein;atM who does such wwk hi cath h
I 'his own employ..,provided that such improvemems son not inkMed woe w "
eek.lf,howa, me building arimpmvenkntusold within oro Year a(complmion,the - - - -
owner-build.will have the burden of pmvmg that he did not build m improve fm pu' •, t.
-pose of seta) 1 / .
I ee owner of W Import,son exclusively coneassim,with licensed contactors to •• _
construct the Mi.,(Sec.7066,Business and Prokeslom Code)The CnU.I&a W '
cems Law ds not apply k an owner of propeny who build,w improve,thereon d
wh convect&for such projects with aconba t (s)licensed purmanuo the Contractors
' Iicenm Law.
❑lam exempruncler Sec ,B&PCfor thisrwnV
Owner. ER' ,. Desk , ,. +
WORES COMPENSATION DECLARATION
thereby
�(havnd will
ntmrminsaandn.kCpeenniilfisycare pod C.x.tkofthelfe-ifnnlulomwmfmgWdaarkaee.C.Impen�-� '
- - � � s „
NO sait..as provided for by Section 37W of the Labor Cade,for the perfomurta of me -
work for which this permit is issued.
❑1 have incl will maintain Worker's Compensation Insurmt.,es required by Section n vi L MYWorYtf Co.?
o. -
PWofinelaborCode,forthepMormanc of the wwk for wh ch Nisi permit is nauW.' - �.
- ?Pe anIn rancec end Policy n�u�m�jf,�yq(['�'Q .,
fCemc' Q C-
CERTR9CATEOFEXEMPf10NPROM WORKERS' - i
' COMPENSATION INSURANCE --
•(Thirsection needrmt becomPlmed ifthc wrmit in fororohurtlred dollars($1 WI
.ar
less.) .. - ♦ .r
ICCs' matlnthe n '
rty rtamber.ofthewco.sabjethia aWminst'Cm.hdl
not employ sa non in sn " �
p y y pe y manner ei u m become subject k the WorYen'Compcn
amivn Laws of Celifomie.Date
cant
.. APPli -.
NOTICE TO APPLICANT:If,after making Nis Certificate of Exemption,you should -
hewme subject to the Warkei s Compensation provisions of the Labor Code.you most J a
forthwith comply with such pravisiana or Nis petmiuhell be d«med revoked. _ , "
CONSTRUCTION LENDING AGENCY t
for whihdiruthercnsued(roemnle,ding agency fonhe perfortwtce,of s' ' s '
- me work for which rots parrit m issued(Scree 3097,Cis.C) "
F > Lender's Name ,
1 certify met have read this aPPliation and.tete mat me above Informed.iv
nnnq,,, 0 conect.I agree k a
comply with all city and county ordimns and suit laws mlaung to _
U O 'building comswction,and hereby authorim representatives of this city W enter upon me f y
above-memioned property for inspection purposes. tv
W ,cy
We) k save,indemnify and keep harndess the City of cupentno against - - -
0 U hurbdiwas,jutlBmenti.costs andexpenses which may in any way nations against said City
'' ^y, W �in conaequesme of rhe Braniingbf tNs pe )t � -..
hAPPLICANT UNU:W A AN fLLCOMPI.YWITHAI.LNON-POINT - ! - •�
f..I UHCE REEC AT
4 S=ao-00
Si mofApp amlCona Data
HAZAR OUS MATERIALS DISCLOSURE
Will the applwant of future Wilting occupant store or handle hazardous...mi Re-roofs'> '
as dafined by the Cupenmo Municipal Cade.Chapter 912,and the HCalm and Safety
Core,Section25532(a)+ Type of Roof '
❑Yes ' gip`, - - t... ' ., 'i
All'roofs,shall be inspected prior to any roofing material being
Will wc
ll me applicant or future buddingoccupant use equipment device,whmh f
mailhamumna taasdefitedbyth.ByArmAuQ hm
ryManagement 'installed. If a roof is sialled without Irst obtaining an inspection .
I agree to reinove;all new.materials for inspection., Applicant
❑Yea ❑No
III read the hazardous materials"me Ibrmnk old. r 5
Chapter of the Cats- understands and will'comply with all..non point source regulations.
forms Realm&Safety Cade,Sections 25505,25333 and 25536.1 understand that if the. -
buildingdwsndcurrendyhaveeknencmalitismyruponsibilitytotrotifythe.Cupmi; -
,of the rcyuinrwnu which must be met pew to iaauen«ore Cenincme of OccuPmry. " '
Signature of Applicant Date
Owner weumonml pm pals , I "
All roof coverings to be Class"W,-or better
OFFICE