00020160 CI Oo FNCDDIVISION
C g N RA t' R I iFOR ATI d PERMIT NO.
BUI
PERMIT (( .
BUILDING ADDRESS: - n /� '
�Q G'R+^ CQ �s �f�/�(l2f ey N/�� _� �� ' � �/� SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: ••+GNf•C Y�-yY sol Aga its- t/Y%�'Kt/^$ i ^� OO
hl Ad (J - /,^__y/./I NIC CONTROLN
C DNI::073-60V 'S�SZ{C� ❑
ARCHITECIENGINEER to ^-,B L IN�E RMIT I[7f0
c'ub
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LICENSED CONTRACTOR'S DECLARATION
o i-� I hertbr.mrm that i.,n Eemaed under ptavi.ira ar Chapter 9(ermmndng Job Description '
with Secuon2000) fDivieianJof the BYaineae.nd flratwions Code,uM mylicrnuis pp//�A)J �t ('
<qFo re uten Pore and cif i - n, Fpp - �Iqp� /. /� A 7 �'�`-/�.k�{�)/,•
s c < License Clw G�'a' Lic.N ��YryX / "`77 I e � • '"
Wie N Dau '9N�-.3.610• Cone _
O¢ ARCHITECTS DECLARATION
v�y f I undcrmuci mY pl...fall boosted u public records '
r UO Licemed Prefectural
w OWNER-BUILDER DECLARATION
t G 1 hereby atfmn,het 1 am exempt from Ne Ceram.Co Liense taw for the
5�C following namn.(Section 00313.Builme and Proportion.Cada:Any city or county
wG r which requires a portrait In construct,Blur,improve,demolish.or tep.ir my anunwe
u3 m prior to its issoance,.lso touches the applicant forsuch pemul m role a signed tenement Sq. Ft. Floor Area Valuation
that he is licensed pWeuant ode provaimeof the Connector.License law(Chapter 9 '
(cummencl."fit Stoic.1000)of Division 3ofrhe Buunw and Proreuima Code)m APN Number OCCU T
Wt to
canis ii emp therefrom and the bei.for rhe Waged eumptinn M occupancy o.Ant violatio _
Secdon 20313 by any applicant for a partner ubjects tie applicant to a civil penalty of r
rot mom then five hundred dollen(5500).
❑I,,.nwraeaardepmpmy.mmremwayee.wimWgtl..meir.aleeanpewtiYn. , Required Inspections
will do thework,ands: he Continence.
ont isnm inuMed Law
a(SecAbH.ownera
and.,win,
Cade:The Con theneo,awl who
lea does ret d,In tom owner gh .
poprny who build,pr urine,tet...h and Who does each intk himself ofered for
his own employee,provided that och impre,schd w na intended c offered to /
sak.ILhownrenllhvei the burden
of
i.sued wild nomild inspro le fomtha -
gam of u0dttwill have the burden or proving the M dM not build a improve for poi-
pe1Yfoe.). ,
I,as awntt of v, property,am unes,anY contracting With Ilmneed conn tors o
O nseLa Ne project'' 206X,B.of utl Pmhulom Code:)The Contractors U-
who taw den mt.pply to N owm Of pnpeny who Budde or improve shaman,rend kVwj/
U..Law. such proleca wish econtr.ctw(c)Ilceneed punumtm be Contruwts -
[I I n law.
" ❑hurt e.emptunderSe. .B @PCfor Nie reaun Q
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby am .under panel"of pttjuy one of the following duWnuau:
❑I havered will meiouin.Cenlficmaof Corset to self-tome for Wprkeh Compare
cation,u provided for by Section 3200 of the Latta Code,fa the peefomunes of the
jCfor'which this panni)is issued,
have and will roainuin Wattle C.Imseuon Insurance.u rcgYired by Section
of the labor Cade,for then perrormmtt of the work for which this purls is issued.
MY Worker C !e�>)tin.tom cecarderand Policynumber
Carrier. /�_Policy No.:
CERTIFICATE OF EXEMPTION'•ROM OR10R§
COMPENSATION INSURANCE "
(This scum need not be cmnplead if the prod t is fa ore hundred dollars(S 100)
or lee.)
I comfy but in the perfonraaaaofthe..it for which this pemdt is issued,I dhall
and employ my person in my number so are to become,aubjec,to the Worcen'Compere.
satiora LawaofCalifamia.Due
Applicant
NOTICE TO APPUCANT,If.after,making thin Ccnifetne of Eumpuon,you should
become subject to the Workers Compensation provisions of the Labor Cole,Yon mut
forthwith comply with cuih provisions or this pmol,dull In,deemed revoked. _
CONSTRUCTION LENDING AGENCY
0 IhertbY eifuen Dar then ie.connvuction lending egeay fa the perfmmaer
ythe work for which this pmrd ie inured(Sec.3092,Civ,C.) "
Undoes Num
a Lenders AM.,
4i7 I mnlfy that I have real data application and ewe that the above infocuation is
Q, correct.l.gree to comply wish dl city and county ordinance,W some law. We,tp
Z) Z buddingcanetmction,arta hereby mthorier representative,of this city toenurupon the
U C above-msmimed property fee transaction purpoeu.
W (�. (We)agree an rave,indemnify and keep h.rmlus the City of Culotm opns'
0 V Iiebihitin,judgtmnu.count wWupmsea which may in my way acaueay.iml said City
sty LT7 in consequence of the among of des pmnit.
.Fi APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-MINT
V z
sou R/CYE�REG�UTAY�ONSJ,�
Si�are of ApphcanVsMRDO D.
HAZARDOUS MATERIALS DISCLOSURE ,
Will the applicm,arfuture Wilding cecupent ntaa orhanNe haraNmc matnid Re-roofs '
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda,Satire 25512002 Type of Roof
❑Yes 21Na•
Wil the applicant or future building occuoccupantcup ,use a{uipn¢m mdevicn which All roofs shall be inspected prior to any roofing, material being
ami,hewda..eir conumimnnt u defined by the Bay Are.Air Quality m
Magm
cen, installed. If a roof is Installed without first obtaining an inspection. .
DietrieO Ia ree to remove all new materials for inspection. Applicant
❑Yrs 0No g P PP
I have reed the harmdone muenale requimmenu under CNpm 6.93 of Ne Cali. Understands and will comply with all non point source regulations.
fano Health k Safety Code,Sections;25505,25531 and 2553x.I uMmurdl lhr if the '
In'
ldingdasna rely responsibility r.t it is my responsibility tmify the oavpmt '
of l name a whic ret be oat Few'.issumen ore a Comfiest.ofOccup.. '
� Signature of Applicant Date
Owmror authodred agent Dau
All roof coverings to be Class`B"or better
OFFICE '