00040042 CITY OF CUPERTINO , . ,�� PERMrTNO.
BUILDING DIVISION PERMIT �' ' R+ �QO��
BUILDINGADDRBSS:
`1 o7frf 0 SANITARY NO. APPLICATIONSUBMfITALDATI
W R'SN M1E� N/C CONTROLN
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d� IN OD iftjL"U O�PENMI .I'4
ANCtiITECT/ENGINEER
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Z FO?3 LICENSPD CONTRACTOR'S D visions ATION '
O 9`3❑ I thereby ailrm vis I un ft Bu under previsions of Quper 9 my lm m is Job Description
< 5 wilt Sarcean00ffic'. irion3 afthe BuiuuW Hefdiom Cade.niod mY liana is
y2 in oNil nme ceed.Rat. � Cd,t^h'c,... Wy
5 O uw1 License Nu Lie.
Conuecur �)w0ji,
C O¢ ARCHITECTS DECLARATION [/
to l underused my pals shell W used Is public records
0.c G O Licensed flofeasionel -
OWNER-BUILDER DECLARATION
1 hereby mfr..tali 1 win uempt from the Cmundeors License Law for the
N F O foilaving reason.(Section M31.5.fluidness she Prolne tau Code:Any city or wunry
�C$ which requires a permit an comma,alter,improve,demolish,or repair any ewetioe
3 prim to its issuance,also intones the splicers for such pemdt to flee signedeuaront Sq. Ft. Floor Area _ - j Valuation O
thatheis licenedpunnant.ot Mvisiomofthe Conuu,ote Lianselaw(Chepw9
([stheismew+thsutiw,009mfervntwrmrrmoged Prorenloucde)er APN Number Occupancy Type
the[he is ucmpt therefrom ed the burr far the a s the caaliam n.MY vi.tadw of 36
O �� P y yP
Sedan .her by hundred
eppgcmt fa•peens'.subjau Ne eppliunt u e civil peralry of
not mart Nen Five hundred dollen y crepi.
❑Las awvn of the propeny,ormy employaa wilb wnifimurbeirule cornpenwion. Required Inspections
will dothewons ads: he Contractor's
Law done apply
1..owrruss
end ertyw Professions
Code:The eves th ur'e License Lew dos trot apply t.lf owner M
his we oral Wilds pa improver thereon,and who dose o work bead or or thrpugh
kir awn empl.yena,p.vrdd r in lath fined,I.menu thin oat intendd or aRcred for
own If,howmer,the Wildtnbar ed of pr vin.in oldddwithin ntu Wild
of rompletior the
puss oW ildn will bees Ute b.vden of proving that he did not W iW u improve for pv-
pose of sale.).
❑n e owner of the property,,Bsnus exclusively Polemicist
t wird:)The,C cor .
ore.Lo rtec.mu.pld,W 7w,Business endrt,who Wi Codo:7ThetParroContractors nil ,. < ��/
Genu law daa nut apply ie en owner of property who Wilda or imm.va thereon,ed
whet ouch pojau wiNaconmcmr(tllketuetl Wnuent to the Conuectola
L law. OA
❑ em exempt anile Se .BRPCfm Ni rcuaP "V'
ow Dne 6 loo U .
COMPENSATION DECT.AIUTION t
• I hereby affirm under Finally ofpojuty ort of the following coamadona: .
❑I have and will maintain a Conificate ofComenuo self-imureforWorkersCompen-
sation,as pmvicid for by Section)700 of the Leben Cade,for the perfomunce of the
.it for which this pares.is tssud.
❑1 have ser will maintain Wohcr a Compensation Inaurthwe,an mquned by Seaton
37W.f do Labor Cade,for the perfonnanu of.be work fa which this permit is tuned. J(~„
My Woher'n C.mpenutiw Insurance<emrer and Polity number au: y
Cartier. - Polity FROM
�Y—
CERTIFlC OF EXEMPTION FROM WORKERS' D �i
COMPENSATIONplass! INSURANCE 6 2000 II �.I
(This rttim and nuheaxnPktd ifrupmnitulororchur,AN dellen(SIM) FPR U
u Ictal
I catifemploy
my per in the pay.oftbc wink for which Ieal 1.permit st .,headed,I shill
not employ of person N uY manner u n to become aublat ro the Waken'Compo^- .
sa.ion lawaof CelH.mte.Data
Applicant - _ By
NOTICE TO APPLICANT.If.atter mddng thin CoMflu c of Eumption,you should
hcome.objet to the Worknies Compensation provisions of Ne Leber Code,you It
foMwiN comply with such provi6cam.,this permit"I W hemd tevAaL _
CONSTRUCTION LENDING AGENCY
p Ihenbyaffim.NUWre
cuaconsuu[don lrndineeBenc3'fm the peAomunced
Z the work for which this permit is iuud(Sec,3097,Civ.C.)
FLend,es Name
((� > larder'.Addreu -
W I certify thin I have red this application and mute Net the above information is
Z cornet.I e9oe m comply with all city and county ordinances sod awe laws relurng to '
Wilding cusuu[tion,and hereby wthorru reprcsenwivn of this city to enter upon the
C.7 above-memiond prapen,for incision..P."an,.
fi Es (We).firee se ave,indemnify thd kap harmless the City of Cupertino against .
Q C.1 babiluiem.judgmens. I.and ailimsca which may in any way accrue agmm,said City
f Nenung of Ns Far .
WM)I' NRAIN
SOURCL RP UI S
� z
PocU
Signemm of ten Doc
scamHAZARDOUS MATERIALS DISCLOSURE
Wilby teCupentor Future Wilding.,Chamnareof hndle Hath uamSurid Re-roofs
u ds,Sc m the Cupertino Municipal Code,Chapter 9.12,sod the Health ad Safety /
cade,satian zss3:an ^`�/ Type of Roof ,
❑ may'
Yen � ° '
.helltire
maWlioam or fume building oc[upent use equipment or devices which All roofs shall be inspected prior to an roofing material being
cmith.sardoebconuunimu
nudeB by Ne Bey Area AuQaliryMmgoom installed. If a roof is Installed without first obtaining an inspection
• °I"""oYe fK to remove all'new materials for inspection. Applicant
o
Ort huudou mtdW rtquirmmuuda Chager 6.93 of the un erst will comply with all non point source regulations.
Tarda Hu1N& fn 303,23333 and 25336.1 uderstud that if '1
buildingdasnw ly Mve nenant. .it ten mY mPouibilirymmtJy O,c.vzV 4 U
.fiWoof musehecon into uwurte otaCmifi of upeuy.
Signature of Applicant Date
thvnerm eta Dae _
All roof coverings to be Class"B"or better
i
OFFICE