00050105 C
ITY OF CUPERTINO - < ^ .
BUILDING DIVISION' - PERMIT ON .I Ph1F FTI p ( 'PERMIT NO., •-
ILDING ADDRESS:
05 S � �ss �x
SANITARY NO. APPLICATION SUBMITTAL DATI
NIC .. CONTROLkCHITECT'/ENGINP.ER I.ICENSEDCONTRACTORSDECLARADON -
oz=
'Job Description '
rryt:.� ween Sectio]000)ofDnvisioe3of CeBmmcnsand Dotueiom Code,aM mylicenae •,• - _
c < In full farce and effect /7 t 5SqS
'
stases C1 1--, ��Lic.N..
6 -toa I ARCHITECTS DECLARATION
1 undennod my Plans shall be used is public rewNs
a a o a Uoemed Professional
uaS OWNER"BUBDER DLA
ECRAI'ION •• "
6 I hereby affirm am I
that I exempt f Ne Contactor' LiceLicart.Law for the -
F O following reawn (Stetson 7031 S,Business and Prifoeton3 Code My city or court, _
3 which segmres a remain in construct,alter,improve demolish or reps r any stmentre ,S Ft.1^"1007 Area.-, Valuation
prior to its Issuance also agmres the applicant foreuch permit W Bleaslimed statement q• n '
,shat he is licensed puauanl to the pmlilim of In.Cwntradors License La (Chapter 9� "
(commencing wish Section 7000)of Division 3 afthe Business wad Professions Cartel or APN Number,•Nal he is exempt therefrom and the basis far me alleged exemption.Any violadan of ri Occupancy Type
Section 7031.5 by my applicant for a permit subjects die applicant to a civil penalty of
not more man five hundred dollars
0 Las owner offlee property.or my amployinns with wages a their sole compareation, " 'Required Inspect'to
will dome work,and theshtrcere Isnot Intended mothered forsake(Sec,7044,Business -
and Professions Code The Contractors License Law docs nm apply m an owner a ' -
prapcny who builds or Improves thereon,and who dues such wask himself or through It
his own employees provided dui such Improvemenu are not intended as offered far -
sale.If,however,thebuiltling or improvement is said widen aIle yevofcompletian,rhe, '
e owner- w'1 -
buidtt will basic Nc burden of previous Nat he did not r v '
Wild ion'ro a for u
P vie 0 Pr- •w�/
❑1,as owner of the Property,runBusiness s any contracting CwishW:[shedoma m
news she project(Sec 7014 erofsed property
whoProfession;Code)Thes.thecrom 1",
cense Isco dies not applyje ts owner of progeny who builds or imptuvee Corton and - /O
whocontraw,for each Pro3eca with iconuacrogO hcenad punuant m'he Contredors '
License Uw. '�'
❑lamexemptunda Sec v ,B R PCfarmi3 icadri
Owner Date CR'
WORKER'S COMPENSATION DECT"AMTION
1 hereby Mrd under Frosty of perjury one of me following declamima:
❑Ihwvcualwillmeinsn a Ccrrifiwaaf Consmttowlf.insumfor WmkesCompn- s
at on,a provided fm by Recd n 3700 of the Labor Code,fin the perfomunce of the .
coo for which this permout is issued.
I have and will maintain Workers Compensation Insurance,as required by Section
of the LaborCode,for drc do...
of me work for whish this penmduusued. l � " •s
My Wotker s re
a man
unce carrier d Policy
Ratio, t
Gao, j _Policy No ,
CERTIFICATE OF EnMPCION FROM WORKERS
COMPENSATION INSURANCE
.(Thi sermon aced nil be comPleredifthc pcmutm flea ehundrtd dollen($100) ry - ,
1 erify matin the perfonnanccofinewmk Por which th apemuuaiaued,I;hall '
not employ any scrern m my manner so ss to become subject to die WmkyrR Compsn- • _
Ration Uws of Califomia.Dass
Applicant - ..
N(mCE TO APPLICANT If,after making this Certificate of Exemption,you should s
become subject'.me Workers Compensation provisions of me labor Cade,you must - -
fonhwim comply with such provimmus or this permit shall w dearest revoked. ._
CONSTRUCTION LENDING AGENCY'
0 I beabY eRrsn mal mem u e wnswcuan leMmg agency(.ribs pcdotmancc of
the work for which this permit Is issued(Sec.3097,Civ.C.) "
F., Ureters Name #
•(yet, Under;Address - -
W.Q 1 cerdfy slier 1 have read this application and ante that me above information is
r+ O carrcct comply me
agree to comwith all city wird coney ordinances and are laws rele4ng to
b , y
a ,ng commission.and hereby authmis repre;enutives.0thri try to amesti'm mer
above mentioned property for ine,satim,purposes. _
C) i. (W ec m save I unity and keep harmless the City of Cupertino against' ,
Q V lubib- judg nu,case deeps as wti Amey in wry wa waeagaimt said City
>r W in sequence me ung of m'3 perm As
, ���
code PLICANTU . 5 NDSAND MPLY 0 _P0 • t ., `
f..) U "EREGU TIO ' .
17
6 Pelican o tot are •.''� t�L s �/' V •�D v I
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building occupant store atheistic haedous material ,Re-rOOfs, -
m defined by the Cupenino Municipal Code.Chapter 9.12:eM Ce Hess and Safety ' -
Cadr,sectum25532(r)7 Type of Roof -
❑Yes ON.
_
Will thea,,licanterfuture Wilding occup:tuserga;Pmeardevices wash All roofs.shall be inspected'prib'r to any roofing, material being
emit ha�rR doax. conaminann as defined by the Bay Area.Air Quality Management installed.If aloof is Installed without first obtaining.an inspection
Diatra No .ic'7 La tee to remove all,now materials for inspection. Applicant
- ❑ g
Ili., androeh asmutedY;nnidtj ttatthe cdi. understands and will comply with all non point source regulations.
fmnn Hwlm Safety Sections 25W5,2333x3d met if me "
bdldtng dao t1Y yf ¢nam Omnis cu t
me u I a6yl C�-npri lo' Ce
(/V Signature of Applicant Date
mmiaea agent 'Does' + _ (. ) ,
' " - All roof coverings to be Class"B"or better