00050020 CITY OF CUPERTINOPERMIT NO.
BUILDING DIVISION PERMIT ` 0
6
0-5-0oa0
BUILDINGADDRESS:
' w.. W �./1 _,100 eDa— (/�ySANITARY NO. AP PLICATION SUBMITTAL DATE
OW�Jf�'� /"'/f C`C•_'lL' /Yaw —" NIC CONTROL#
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ARCHITECTIENGINEER
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z o=Ni ED CONTRACTOR'S DECLARATION
o=_vthralls,hcrcb tw 1 am licsuedthralls,provisions of Chzpter9(comm uatung Job Description
with Section )a/Div siroloftic Buuse..and Profewaima Cade.what my lispsu
y� in full Force d effect. �O• '.n✓ ,r-z�', z-� /,r/ ,�/
OdU Wceme Cl WaY
B LL y Date Com ,w� 1. V N.
k O eJ ITECI'S DECLARATION
In my shall u Public �,/r.•-g._�` TG a�t•f� O/
o We u' I NER-BUILDER DECLARATION G � v• —C/LO vi eAF
>' 1 h afllw Nat 1 em exempt from Ne ConttncsoYe Wuns hero fm the
OTo .son(Section 7031.5.Busies and Professions Cade:Any city or county
$
who
Prior ulm e t m cmuwcl Phar,ire demolish,a en smcwe
3_ asig signed Sq. Ft. Floor Area d�VOalu�ion
muits iwauance,siw rtyuirtstM apphcam fm such pewitmfileaugd sutcmrnt �J
that he is licensed parrot to Ne Previuonn of this,Communes Unarm Lew(Chaps 9
(comrrcnaing wird Seefice7 0)of Division 3 of dee Burins am Pmfenims Code). A Number occupancy Type
that he Ta exempt therefrom and ds,basis for Ne alleged exemption.Any violation of P y yP
Section]031.5 by any applicant for.pewiuubjects the applicenuo a civil peWty of 3 O
nJIt mme Nen five hutdmd dollan(2500).
J6�I,wa ownerof dte progeny,
or my employs.with wagewa man solc compe...com, Required Inspections
' ailNotheweek,enddeeawcturci not inteMedoroRered fm We(Su.]061,Buupewa
and Profmaln Cade:The Connector's Wins few don n appy to an cross a
Publicity who buil&or improves theson,W who do inch work himself or thmuglt
his we employees,Provided this,such imp ovemenu sic am inunded s offered fee
We.If,howesr,dte Wilding m isepsovcrns la sold within as your of uncommon.the
owner-0uilder will hive site burden of proving Net he did am build ar improve for pm-
pesofeue.).
❑I,u owner of W progeny,,Business
i mes and
Protracting with 0 The d rnmerccte, m
conswcl Ne Ay]014,Bualos end by whe builds
Code:)The Conoectoh Lt. _
censelaw atrota lymrn awnsofproper.sob Wil smite Wmetheeeneeend
License aro fa projab wiNeconanctorfM licensed punuwmNe Cansrsmta
01 Lew.
❑1 un Pse .B k PqC for dos Kasen _
Owner DeP S
ORnder COMPBNSA ON DECLARATION 1'tr
ysffiw andspcnelty to of oryoroofthe insure fm declarWWkeeun: .
❑I viceM will minuinaCeniEcne afCansntmslGinwrtfm Wmkera Compen- 4 nj
senor,as provided for by Stwom 3700 of da labor Cede,fm the Perfozman of the
work for which this pewit is issued.
❑1 have arm will maintain WntYce.Cothpenudon lmunnce.as squired by Section
3700 ofthe later Cade.fn dee performuce of do work fm which this pewit is named.
My Worices Cmnpenstiw Insurance carrier and Policy number art:
Cuuer: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' f
COMPENSATION INSURANCE
(This sctimmednut baccmpleted if Ne Powis it formehumreel dollar(d100) ~LJ
roles.)
Icenify that in theto
awwhceof the, far subject
1.the WTsisued, fuse-
rot employ way peon ia any mrnsr w n to becom aubJem to du Worker'Camper-
AWli Iews of Cdifomia Dwhe
NOTICE
wt
NOTICE b APPLICANT:If,after reeking Nb Certificate the Labor on,yro uhmulst _
hamw:subject y it Wmkefa Compensation provision of tic labor Cade,. must
forthwith comply with much Provisions m this pewit shill be dsmed revoked. '
CONRIRUCTION LENDING AGENCY
Q Ihetebyafrewthetheremscan.tmcdon lending ag<nty for the prfome.of
the work for which mi,permit is iuued 1Sa.3097,Civ.C.)
'err Lenders Name
a Len&Is Addman
W 0 1
modify that 1 hes sad Nis eplihmaiou and zme that the above iNozmtion is
corrat.I agree he comply wird all city what county ordineoa sed ante laws relating in
U O building crosuuction.and hereby authorize rcpreaenteiveamfthiscity,m mue,mm.the
above-memioned papery fm Inspection facilities.
IT. (We)epee to wars.in&mrtify and kap bawls.the City of Cupertino apinst
U thbibucs,judgmm.,costa am expenses which may ie any way scmeagemitseed City
W in consequence of the granting of this samit.
Cl- APPLICANT UNDERSTANDS AND W ILL COMPLY WITH ALL NON-MIMI14 '
f..l Z SOURCE REGULATIONS.
A
Sigmtusa(ApplicanVComector Dau 3 �V
HAZARDOUS MATERIALS DISCLOSURE
Will the applicst or futon Wilding acupammneor handle hazardous material Re-roofs
as defined by the Cupertino Municipal Cade:.Chapter 9.12,W the Health aW Safety Type of Roo
Co&,Secuon 25532(.)7 `yp
❑Yes )(No
Well the a,ficans m furore Wilding acapmt use equipmcm or devices which All roo s shall a inspected prior to any roofing material being
emit hautdous air contaminants as efined by the Bey Arca Air Quality Mwhagemevt install d. If a oof is installed without first obtaining an inspection
District?
I afire to r ove all new materials for inspection. Applicant
QYs AN. d
1 ve dRle.>.<dmnm�ri.lam,aircmrntaatderGhaperg.95nf�eeal;- un er to and will comply with all non point source regulations.
fom4 H Safety Code,Sectio 25505,25533 aM 25536.1 understand the if the
buildin urnnlly have a tenant,the It is my responsibility m notify the acupium
khmw be that Prig to isuenca May
((� Sig t e ofplicant Date
Ow o rized agent Dau
All roof coverings to be Class"B"or better
OFFICE