00050069 CITYILDING DIVISION C0NTRACTO N: PERMIT NO.
PERMIT L�
BUILDINGADDRESS:
SANITARY APPLICATION SUBMITTAL DAT
OWNER'$NAME: tom— IA . �P�� LC�I� r ' � a0
♦E,`4� \�L \p-x75'1. 'E;'&S> C NIC CONTROL#
HONG: /?nem 1-1
fo�0 — \l7 /L•-e�.a`--c kN �' r ��. . t//le V1.7
RCHITECT(ENGINEER - ` 04s41G:'��jl—[�j BOLDING PERMIT INTO
n c z
CFO_F
WUV
r6a
LICENSED CONTRACTOR'S DECLARATION -
Z O NO z 1 hereby affirm mal 1 nm licensed un&r pmvisionc of CM1ainer 9(commencing Job Description
OdI wimsection7")of Divis'on 3Ofinn
e BusineaMrevos
Proioos and my limeis
in fullforce and Wat. SZI�Z ��
a i Lianu Cl Lic.N t.]M N} �"rC3- ��Q`M"L�C ']= O '
S u H Dete , Cont .of �f�� 5 L CLJ
F Og ARCH ECIARATION )
Qo a oM mr vl.nxw romir records QEl�d--s.. ^P�►-'Cltpepcie� \ '�b�llg��:i' lr- E
i o LL ter asmw e b ELoO+ C�e1
OW -BUR.DER DECLARATION
C?< hertby a fum mal m exempt from the Contractor's License Law for the
a❑ fol ng mamas.(Section]03 1.5,Bminess and Profmiona ewe Any city a aunty
Sw rrouires a permit to construct,ebur'improve,demolish,or repair any""core S Ft.Floor Area Valuation
prior w 11,imeotce.also legorrea the applicant m
I...ch prym t file.signal alancot 9'
that he is licensed pursuant to the provisions Of the Cmmoor.License Law(Chapter 9 \ O ala
(commencing with Section]0110)of Division 3 ofae Boldness and Profeuiom Code)m
wt In,is exempt therefrom ad the basis for the allegro exempt=,Any violation m APN Number •cupancy Type
Sudors 7031.5 by any applicant fora permit sobjects the applicant t9 a civil pendD o f15 j
nom than five handled dollars(5500). o 7` ^✓
rod m
I,uowna of thw propany,mmy employers with wagon meiraolc wmpcmadOo, rt-11
l® s quired,Inspections
wdldotheworkaMthe sauctumismmintcM moRaedfinek(SM.]ONa,Busimas s�
aW Pmfexdons
Code:The Contractor's License Law does ON apply to an owner Of
property who buil&or improve 0 mon,and who does such work himulf m through
his own employes, owidd Iw such improve.."are nm ime bed m oRem l for
ade.If,hmvever,the Wilding m mr,somemenl is sold within one year of completion,the Yl
co e.1n iter will have be burden of proving that he did and build m improve for pm- fb
rose of sale.).
L comment owner of the propany,ase sine si ms and crosacans with licensed conhactors i-
—Lathemojem(Sa91all.w..fpropry who Wid..,OThe Cmwcme.Li-
cense law does rota 1 to n owns of ro n who Wild..,improve thertnn,end ( �.p
pp Y p pr Y w 1.',�.....t a.. A
wW anvactsfm wen projas with acanha.or(s)lic<md pursuantmthe COnmcror's V' aY @(�; q'N
Llcenu law.
❑lam exempt un&rya. ,B&PCfmthisrcamn �::•.n,5' x
Own. Dare,
WORKER'S COMPENSATION DECLARATION
1 h.eby aRrm under penNlY of perjury One of the following declaatimu:
I havw and will maintain.Cwhicam of com d,m sebrimarc for Wmace.Compen- _
tion,es provided for by Sadon 3700 Of me IaM,Code,fm me perfir.of the
work for which mix permit is i,aued.
0 1 have and will maintain Woroms Compenetion Insurance,as le9uired by Section
3'r000fine labor COde,for the padmmsom Ofthe wink for which this permit is Heard. D r
Wo e& u nlnam.ayNay mhrae 11 ZOOO
Comer
CERT CAM OF EXEMPTION FROM WORKERS' �►LEp' MAY
COMPENSATION INSURANCE
(This matin need not becompletwifthe pnmit is boron Winded ars HIM
or Ras.) '1 9 2002
IYthaln the parfmrnasnaa of thewmkfor wM1ich thiap.mit iainmgl pc- G - p�
not ploy-Y-any person is any menn<no ono become wbjauo the Warkere'ComB
seri laws o(Califomia Dau
MI 'LDI,V G
E 30 APPLICANT:If,after makenifiam ofExemption,you a
making this C ,
subjectmme such ers
Csco,co is eddi, xos thelabra Code,you m'
with comply with such pmvidons or this oemnil Nall h deemed revoked. '
CONSTRUON LENDING AGENCY
0 0 IAercby NBmuw mere inCH"metro#°.lending agency fm dw perfmmace of
Ih<work for which this pamtit is i=(Sec.309],Civ.C.)
E. lender'.Name
[� "j Lender's Address
aW Q 1 certify the 1 be.red this application and iwc Out me above infor moon is
Co.,.l agree,to comply wit dl city ad county mdinaees and some laws rtbning he
U O building connow cion.and hereby amhona mprtsenotives of this city to enter upon the
abovcmentionwd property for inspection purposes.
It. [r (We)agnc to eve.indemnify and kap homeless the City of Copernican against
O (� Gebairies,jodgmeno,Coss and expenses whim may in any w.y..a again,said City -
} W m conuqumce the g g of this permit. '
F d 'PLICA#' DI:RS NDS D WILL COMPLY WITH ALL NON-POINT
V Sn"RCI: if LADE S.,
_Ig Appal' UCmmir err Dae
HAZARDOUS MATERIALS DISCLOSURE
ill theapplicenI or fuwle Wilding occupant store or handle haaartlous malerial Re-roots '
n d ncd by the Cupertino Municipal Code,ebaper 9.12,and the Health and Safety Type of ROOF
Code.Salim 25512(°)?
❑Yes ONO
Will the applicant°rfuture Wilding Occupant um equipment or devices whichAll roofs shall be inspected prior to any roofing material being
emit haeNous air crnomimns a&Based by the Bay Arca Air Quality Management installed. If a roof is installed without first obtaining an inspection
i", M ew materials for inspection. Applicant
❑Yes �No
*i1dingcurnsently
me hew,,sin,aircmemsun&rChapw695ofteCali- omply with all non point source re ulations.
ely COde tin 2350°.255']3 end 25s3J.1 underswd mat it the
est e.thaitlsmymaro bilitywnmifytW Wilne wNc est vim so issuamm of a Comficate M Ocmhm,. �J Ir act Date
Da coverings to be Class"B"or better
OFFICE