00020039'CITY OF CUPERTINO - . •, PERMIT NO. '
BUILDING DIVISION PERMIT
' 3�
eWLDING wUUROgg: /may is., • SANr PARYNO.,r APP IC O S BMITfAL DATE
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ARCHITECGENGINEER , "(, /✓/D, 4 / ✓ I�•C/I L s, •_ -r r P
ZO h LICENSED CONTRACTORS DECLARATION . ..., .
O Z — O 1 hereby affmn We I w licensed uncer provisions or Chapter 9 (commemm�g 'Job Description
F y H j with Section 7M) ofDivirentri3ofdn Business and Professions Code. and ylimnse cs
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Clue Lie.
g^OHO Date -I
Date
id 3 u. N 'i I—r I iDECLARATION
H O ''' ARCHITECTS DECLARATION •� ' d
v� j, i undenund mY Plans shill be used as public raordr
resp.
o, emed ProfeulcnalIV
- .
t OWNER -BUDDER DECLARATION „
< 1 hereby affirm that I am exempt from the Commences License Low for the -
ofollowing nown. (Section 7031.5, Business arta Pmfessom Code: My city m county -
which requires a permit u c trunim, sham, improve, dormiah, or mpah any ssrocwre
' Sq: FL Floor Area 'Valuation
priormiuiensedFrmsrtgdns thsslah sofant for Comrowea ofile aicaussigned ne.pt. 9 - a
that heislice with
pwnuant m Ne of Division oftths, the Business
License Lew (s Cosim r
(commencingwit therefnt rom and the basis
for oftheeged exempt Professions
n. Any glen a of - .APN NU bar "- Oceti ane `I� e
Natio is 31.5 b may
and the burs far Ne alleged exemption. to Any violation of p y' • y p
Section ]031.5 by any eppticenr for ° Permit subjects the applicant to a civil pevlty o(, �. "' �: ®10 el
'
nm mom than rive hundred dollars ($500).
❑ I, as owner of the Properly, or my employer wire wagesu theinolc compcnsaan, Required Inspections
will do the work, and the strvacere is not intended or offered for W. (Sri. 1004, Business
' and Professors Cade: The Continuities License Law does am apply to an owner of
property who builds or improves deenem, and who dm. such work, himself or through. ,
f his own employees, providW that such Improwmeen ere not inteMed or offered for
sola If, however, she building or impmwemrnt is sold within one year ofcomplaion,Ne
rowner-builder will here the Wodmn of proving them he did net build or improw for parr-
poseo(We) + ' .
❑ owner of the Property, rni
hes exclusively contracting with It
censd cminmon to
consw o the projcem (Sec ]044, Business end myProfession,bur Code:) The Convenors Li- / ..
cense Law dues nm apply to u owmr of prapeny who builds r improves Contra, n s � s
Who . Laasfarsuch prolecu witM1 a conwcmr(s) hcensM punuenl m Ne C°ntncwra
.. Licentt Law.
❑ Iameaempmunder Sec. ,B alk PCfor this reason _ -
�.. `Owner Date.i ..
WORKER'S COMPENSATION DECLARATION t'
1 .1 hereby affirm under porosity of perjury ore of We following declaration:
40 ❑on, end will forbyneCM,Rnm of GOnrnna ost, for
for Worker's Comp the -
nuon, provided For by Section 3]00 of me Labor Code, for the perfonnanm of the
work r which this permit is issued s
have and will re m min Workers Compensation Inamer,a.u required by Section s
•3700ofthe LaborCook, Urc performance of rhe work for which this pertnim is issued.
Mywo r Cpon Insurance carrier and Policy 9Vm
ner:
cai�Uhlr m�9penaemiQ0&1 Policy No.: C17JL1[nn�)Q lf�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This secdnn ueedtmt be completed ifthepertnis is forone M1undreA dollen(5100) „ '
` Icenify Matin the perfonnemo ofthe wmkforwhich shiapemut is iesued,IMill
'not employ any person lis any manner m u m become nubjarlo the Worker' Compcn- ,. '
span Lawa of Caifamia: Dan. .. '
NOTICE TO APPLICANT. If, after making this Cenifo:ate of Exemption, you should
become subject in the Workers Compensation provision of the Libor Code, you must
forthwith comply with such provisions or Nis pamith o all be dnmed revoked.
' CONSTRUCTION LENDING AGENCY i
Q IhercbY affirm to thea is acum miction lending agency for she perfomunce of
the work for which this pemtit i° issuwi (Sec. 3037. Civ, CJ
Lenders Name
a 7 Lenders Address
W A ' I certify than I have read this application and some that the above information is _
4 , commit. 1 agree ro comply with all city and county ordinances and sure laws reining to
U O building construction, end M1ereby million.nprcsrnutiva of this city to enter upon Ne
povo-memioned property far inspection purposes.
W F:. (We) agree io wave, indemnify and keep harmless the City or Cupevino against
U lioulitiea,judgmembcnrsand expenseswhich may in any way acerae again, said City -
^�, WQ to ccinser,tinme of One granting of this Permit.
a
PCUNUF. 'TAND$AND WILL COMPLY WITH ALL NON.pOINT
SOURCE RCE RE RE
�+ Signore ufA U mnctor I Time
ARDOUS MATERIALS DISCLOSURE
Will Ne applicant orfuture building occupin store or hacdie Woodcuts material Re-roofs'
as defined by the Cupertino Music I Cade. Chapter 9.12, and the Heath and Safety ' `-
code, slmyon 25532(e)] t Type of Roof
[-]Yet NoWill the applicant or future Wilding occupant use equipmant nr devicas which AllToofs shall be inspected prior.to any roofing material being'
emit hazardous air comerninants as defined by the Bay Area AU Quality Management installed. If a roof is installed without first obtaining an inspection
Dia"let' - " •I agree to remove.all n materials for inspection. Applicant'
❑vera °
understands
haw „dh,,,ao;makriil,reg�;re nte°naech,p 6.95af� maia dw', comply.with ,all'non.pointsource, regulations.
fomu Health & s m Code, S rlRus 255(15.24533 and 25534.1 undersand thin if the
n
., Nm1m,=.oa p ate..at, chat ire is my responsibility to notify the occultism t .Z
of the reyuircn>Gnr becnem Prior w issuance of a Cot fico{e oI cupidity. •, r�
?�1 Signaiure of Appl t - Date
Owner or aumenaed r 7"Dare, .. /. '�
All roof coverings to be Class "B" or better
OFFICE .