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00050022•a' CITY OFCUPERTINO - - -PERMIT NO, , .BUILDING DIVISION PERMIT �q BUILDINGS©'0ZZ. ADDRESS: J - V - •' 2t h ff SANITARY NO. APPLICATION SUBMITTAL DATE OWN 'Milll/ I l..i LI��'JJJ ✓ IY'/1!�(�(/ ` : //^�j /�L�. N/C - CONTROLN' PHONE tJ //r j, .. ❑ 0 ARCHITECT/ENGINEER, •��. V7LI�V.�/' ���✓ U [TVfSRP@Rtv1IT�l F. o z�p4i= �� `r' LICENSED CONTRACTOR S DECLARATION - o O 4 n . ' 1 hereby.,,.LICENSED the,I am licensed under provisions of Chapter 9 torten aavg u " 'Job Description .. , O m t• wtNSalion 7o0o)atDsvision3 ofrhe BusinaamdProfevnoR ode and mylittnseu or in NRfotttand1 q FY/5T//uG WOOD SHAice5t w LscenoeC�9/��LIL.0 w 3 LL D.R ^f T—Gomm mr /'/�O po5cD ASPA9 L'r 51*i714�1� g I unimitund my plans shall k used u public rtn � oL n d Pmfe Tonal It'!26 Ul MFC,2: INST/3/-L-A-T/ory 5PECS�: A� . u"7— OWNER BUILDER DECLARATION 3 4 - 1 h by Rrm met 1.. xempi from Ne Connemara Lune Law fm the F M toll g redo Section 7031.5.B siness and pectoral Cade Any my or uroaty a 3F which orprm.a permit to conalmct.Iver, prodemolish or repair any stmcmre - poor in t issuance,alsomeaner theapplicant( such permit m file a signed statement Sq.Ff.Floor Ai'ea Valuation/ Nat he is licensed punualn to the provisions of the Connatoro License Law(Chapter 9 (comtiaencingwimSecdon7000)ofDivisimr3oftheBusimn.iidl ofeviarocaae)ar' 'APN Number ' ,' Occupancy Type Net he is exempt Narefmmd athe basis Forms alleged exemption.Any violation of P y _ .Section 7031.3 by any epprcmt for a penniuubjectsthe applicant to a civil Penalty of g. / G2 •' - ot room than five hundred dollars(5300). l,aaownerorh Propnr.armr mploaswiNw.g[. bb.nieLampn.dan, Required Inspections will doltswork,sedtheeoCoreisnotiLiom Law to owner -and Profession.Cade:The Contractor's Liana Lew d&o nm apply to if owneb of hpropertyis own who builds or improves diversion,and who dery such time tied or of Nrough - his own employers,provided Nat such improvemrnu ere not intended or oRcld for comer-Wilde,a,ill boil dingorimprovemenl is ml ho did a Wild or fomur- i. own bultl Il Wonche buNen of provt 6Net heeded obis ld'a improve for pur- pose myou of bale) ❑1 f property.en exdus ad conbacun8 odone ha noes 1. + conslm t the protect(Ser 7044;Business ad Professions Cd c )The C trmu Li ec - can. law dain r pplyroenorinerofpr perry hobuildsmiant a Ihereaa a A - wIm contacts for such projects wlNaconrr.dorls)Iicenaed pununntm Ne Canrredors - s V License ❑l am exempt under Sm. .B&P C for this reason• _ - - „ Owner ..i Dam - .. WORKER'S COMPENSATION DECLARATION I hereby affirm underpevlty of perjurymer of the following cimlerstiotu: I haveand willlvlvwneCemBtttc otCoauenl to self-insuR fa Workers Compen- , M setion.'es Provided for by Section 3700 of the Labor Code.for the performaaRe of the k for which Nis pe t seed. I, f�,{jI have and will maintain W dRrs Compensation In uretRe,es rtquired by Sertion wJ]00 of ire Labor rCM4yfor heyplf<grffromenrrtt,ffth- mkforwluch this permit tahand _ • ,. My W0)90S•C4/Li4/1/YK nu .. ) " ' Comer CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE � • t (Thi�sasinn nednm be comPl<aedi(Ne pertnil ie lm one huvdred dollars(Slip) ? niers.) I certify that in the perfannume mine work for which Niapemdt is iscoed,l shall intent Ploy any peuon ne m any manr m as m beme Ne comb-1 to Warkera'Compen- .. - union Laws ofCalifomia:Dale Applicant - NOTICE TO APPGCAN E If,after making this CemficaR of Exemption you should bceome subject to Ne W tears Compensation provisions of Ne Labor Code,you most fanhwith comply wiN such Provisions m this Permit shall W darned revoked. z CONSTRUCTION LENDING AGENCY , Q �.C7 I hereby affirm that Nem is a conwmcdon lending agency forth<performance of the work for which this Permit is issued(Sm.J09!.Co. C) E,y Lenders Name .. - . , Lenders Address .. - a' 1<ene Net I have read this application end site Net the above tis relulion to k7 Y PP - ly Q' , buirtm.I reed et con 1 with ill cit eiz count ordinances of and cum laws r upon to ,. a6 PY Y Y g � 1 buildingconsncdpro,and hereby inspection purposes. of this city to enter upon du U O above-(We)are to Baia,rindemnify an keep fa. W ty erju agree m cove,indemnify and kap harmless the y.c ussag est s against - Q W liabilitiec,rydgnlems&md.j efonaeamit. may inany way acmeagainn said City ^ry 0- in APPLICANT of Ne granting of Nis permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT �/PJ V �.. SOURCE�REGOLATI a � � •... 22 �J qy�/.�c-,� Signawre of Ap anJComm Dam I V� /a,(J V' ' r +� HAZARD US MATERIALS DISCLOSURE v ^- Wlllrhe r building acupanumRorhadleharadousmmeial Re-roofs - - se defined by the Cupertino Municipal Cade,Chapter 9.12,and Ne Heath and Safety ' Ciale,Smt an 25532.) Type of Roof. - - the or future building arupaut use egtipmem or devmes.whier All roofs shall be inspected prior to any.roofing.material being Will ' emit Wearlous air contaminants u defined by the Bay Area Au Quaity.Management installed. If a roof is Installed without first obtaining an inspection' • °"`°"" o 4, I•agree to remove all new,materials for inspection,. Applicant • ❑Yes Nd .Iheve reed tiler dour materials rtq irtmenis ander GluPR bas afdR Gal. . „un efstand`s'and will comply with all non'point source regulations. (mild.HaIN n Safety Cade,Savona 23303 23333 esp 23334 1 to ed tMt If N l .. 'a building door not currently Mvea¢ninl that tiamyica a.ibiltym otify Ne acupanl L. of the aWuiremenraw ' m Ile ten psiorta iasuence a.C, of txL - 7� Signature f Appliean Date ' Owner or euN edegem . ate' ` � _ . All roof coverings to be Class„eB”or better' ` - . OFFICE