00050129 CITY OF CUPERTINO eERMrtrvo.
'rUILDING DIVISION PERMIT COO NIRA TOO INFOO ATI®Ns f �� JG d�
BUILDINGADDRBBE���S:
SANITARYNO. APPLLrICCA-TION SUBMITTAL DATE
OWN,fr:R'SLINAME:
Al( /W� V FA [� , ,� /r 1 NIC CONTROL
) 10
1` ICHITECIENGINEER ISULDING i!ERMfItINfO
444 Eg�guC
t_D i LICENSED CONTRACTOR'S DECLARATION
OZ=_ I hacbY,ffum that I are licensed under provisions of Chapter 9(comt.ocing - Job Description ,
HC$� iniNgareemalefecDivisian3of tneBminessaMProfevions Cada.Wmylianu is ^ �J^I � `
ed N in roll force mdeRen. s �.'
"'555 O m u .License Clare La.M s..•l�v s"1
. ;a F . Dem Convector
t
o.0, ARCHITECTS DECLARATION
Qo I rndenremd my plw Mail be uW as public rtcords
n .Licensed ProfessleaW
OWNERBUILDER DECLARATION' L
(=Z a 1 hereby aRrm that I am eaempt from Ne Committee.License Law dor the
I F a follwnng reason(Section 7031.3.Busies and Pelessiou Cade:My city 6,money
a m which requites.name,.,..Inset,alma,improve'demehsb,m repmm any mrcure Sq. Ft. Floor Area Valuation
peiutOlts ixsuanee,also rtquirts the epplicent Tea turn permit m Ile a m,red alimm ent I
that he is licensed pursuant to the peovisiom of NC
e onmulers License Law(Chapter 9
(mmmenamgwiN seaden 7t100)or Divimatt3oftlre Budnsuaw Prole..ions cade)ns - APNbar ecu arc Type
Nat he is eaempt Nerefmm IM the basis for Ina WcgW exempcon.Anr violadon mf 5 PY YP
Sermon70)L5byuy Vphcmtfmapermitmbjmtsrhe,ppli.tmscivil,e ,Yof /_
me moo Nm fie hutdu l dollar($5W). YG+
❑Lmowher orthepropery,urmyempinyse.wim wage.as dicks .moripariumm. Required Inspections
will dmhe work,end Ne structure is not intended in offered for sale(Sm:7W.Business �.
and .1 ions Cade:The Coauactui License Vw dos trot apply ro an owner of /) /f � —2 --y
hiswproperty wbo builds or wiftclvu therum.and who doe.such wmk himself umadf r (/ ( /!� t
his own employees,provide.Inst arch improve...
ent is sold u thin on ieseMM a offeree for
sale, buil ding.erofprovin iuoldwithinonsilvcar Trow finger.naha -
Wilda will have the burden of proving that he did not build u irltprove for Pu.
e /-fry//
a,
owner of the property em eaclumvely ces railn8 with licensed contractors m / �7/—S /Q�
mme Law
d project(Sm.7014,B cor.1' rope Rofeulua Code:)ld a Cuhemen,Lid / v
cense taw does ret'Ply'.ts owner mf property wice sed p ret imptovn Corme,iend
ns
who conhmtsfeasrch pmjau witheromm�or(H licensed pursmntmthe Cmnuacmh � ,
License Law.
❑In mesemptinda'soc. ,B&PCfm Nis leu. •' - _ '
0 r
WORKER'S COMPENSATION DECLARATION -
I hereby affirm under mm,.f of perjury rete mf flee fallowing decision .: '
IAIhrwmd will'uireim aCerv
ificall.coentf.selLimuu(.Weaken Cooper. '
tion.as Provided for by Section 3700 or the Labor Code.for the Performance of the
ink for which this scrmh is issued. � _
O 1 have and will Imimuin Wohcrs Compensation Imursem.as required by Sa iam _
37Wcf the labor Code,for the perfomume ofdm work fa which this permit is dewed.
My Workers Compensation Insurance cartia and Policy number see:
Camiec 'Policy No.:
CERTIRCAM OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(This ia-fine need lou becompland ifthe permit is fine.bundrN dollars($100)
or Iass.l
I ccnify Out in the performance of the work farwhi,h this permit is issued.I shall m
not employ any person in my manner so as to become.ubject to the Woken'Compton.
.tion laws of Caiife.u.Dau
Applicant
NOTICE TO APPLICANT:If,enter making this Certificate of Exeupdon,you should
become subject to Ne Workces Compemation provisions of the Labor Code,yen must _
forthwith comply with tech provision or this permit aha11 b<datne t eevam.
CONSTRUCTION LENDING AGENCY
O I hereby affirm rw there i,.monistical.lending agency for the parks.of
r the weak for which this pcmdt is issued(Sm.3697,Civ.C.)'
Total Name
lancers Addreae
(gt 1 ccnify slut 1 be.rust this application and item that the above ofoesmtiu i.
V 0 mrtecr.I same m d comply with rel city red county cadmium.ansum laws relating to -
building consbrcnon,and hereby mcbmis<rep asmoriw s of Nis city to enter upon the
u»v-trout oned property for inspection puryoses. _
f+A Fat , (Wa)agree to save.indemnify am kap harmless the City of Cupertino against .
O U liabilities,judgmanm,casts and expens which may in my way acme against said City
�+ W in consequence ief the granting of this peon'.
E+ ar APPLICANT UNDERSTANDS AND WILL COMPLY WI'1'HALL NON-MINT
SOURCE REGULATIONS.
Sigumreof ApplicenUConttsstu .. Dam / s•/ �O i,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant in.building rccup., uhudle haardous materia Re-roofs
as carload by the Cupertino Municipal Coda,Chapter 9.12.W the HUM aid Safety
Cana,Section 25532(.)7 Type of Roof
' Oyes ON.
Will the epplicant or future Wilding.Upent use equipment or devices which All roofs shall be inspected prior to any roofing material being.
emit Inactions Sir contthiuu fined
nnse deby the Bey Area An QmManagementlity Mgement installed. If a roof is installed without first obtaining an inspection
°'`""'
O Y<s No I agree to remove all new materials for inspection. Applicant
�' O - d
ae ,,d�n,,dnnmm. m„9;rem nhr d h.
r� pe 6,5nfdmCm;_ un erstands and will comply with all non point source regulations.
Immix Huhn&Saimy Code.Se6 m 25505,25533 and 25534.1 rndenund that if the
building does mot currently have a tenant.Esu it is in,re+Feasibility m ratify use W,
of Ina re,mammtta wNch must be trent priorto issurce of a Certificate of Occupercy. J r U 1 [SXX�
Signature of Applicant Date
Owner or euthonzed seem Date
All roof coverings to be Class"B"or better '
OFFICE