00050137CITY OF CUPERTINO ,- --
BUILDING DMSION PERMIT
l[F I '�
PERMIT NO.
' -
//_/+"
`141"
///,N'��//
•
BUILDING ADDRESS:
/O�OO ��'• �Z�i-- ••�/��r ..' t
,�p� l^�/ _
,.`�
SANITARYNO.
_
APPLICATION SUBn TTAL DATE
5��.-.
'
OWNER'S NAME: p /J,/`G
p 'o _,
/S,/'/Q�t•
!D �'GJ/�' V'�•,� 7
+Q P�
N/C
- CONTROLN ,
bra.,
oYD •7e
HONG 4c +p•'L`/OVa�IO�%'
v ❑,•
ARCHITECT(ENOINEER
H=
I 3.. LICENSED CONTRACTORS DECLARATION'
.
2 s•.
o Z = o
' hereby aPom Ntr 1 am licensed Me ivons
pro of Chapter 9 (commencing
J ob' Description �
r•, (:w
4yiQ
5
wiNSahon 7") ofDivnsma 3 ofNe BusumesiondProfiessions Code, and my lams is
mfullfor«andeRact
nen/. ..
IJ«e Clap Lic
-
� •�/rj/�v a,�, Ly„� � �P Owe �On//lV rK
3 E F
N
wV'I
Date CwVMmrTrEfq
yOo
•. 1undertreM my, Plana shall as es PL Curds
✓✓✓tti / 1 / / �i
�YH.[/ '..•�•�ya� /�O� �itQ ///(/!vs-,I/aMN �E(as
n, o
Licensed Pmks.mi,nl:
j
Z_ ¢
,IOW EC O
. ecti that 1 aemrPt ontracmr ense
1 hereby R 'L cLaw tin
�1� •CJ U/
R o
toll B t (Section ]031313 . Buamevs and Pmfaaronv Cade MY my owcounty runty
• - -'
am
i C
which tortuous.m delish or rtpav stir asmcuve
Permit to cowc, alter, improve mo
Sq. Ft. Floor Area
Valuation
1
prior my lie eppi pemu gimds
to . ,:Iva mulches applicant tsofileas, statement
-
that he is lncnued pursuant to the pmvrsions of the CwnectoteW«ecu law (CWpter9
'20' DDo - •-
-(commcnnng with Salon ]0007 ofDrvivw3of Ne Buxn«as aid Prof ons Code)m
that he ,s acmpr therefrom and Jin basis far the alleged exemption Any violence of
/� ^ APN Number
a Occupancy 'Type
Section 78315 by any applicant for a pend, subjects the appl antic a <, i1 penalty of
+ .JC/.�
eat moo then five hundred dollars ($500).
❑ 1, as nen w nrN prop rty. m ter empmyee: with wags M their:ole namp a atian;'
Required Inspections'
PONCWons and Ne she CWfel6nmlLicensmaw tie
'
and not
and Professions Cade: The Contractor's License law does lint apply to en owner of
do apply to ars come""
builds improve
-, -
property who or thereon, erd who does stili work himulf or through
his own employees, Provided that such improvements are not intended or oRered for
-77,3 Z. 8 ,
1 .
mc. If, howevea the Wilding or improvement Is said within line .of wnmleuon, the
owner -builder, will nave the WNen aproving Nat he died nm Wiid ar improvz for qv-
I .
POS1 Of 6file.).
+ �k r
I, tenser of Ne Property, adus conmutng wen li«naal
tI-
construct (Ser: ]awe . B erect r. I
and Professions Cade:) lee Cantiecmr'e
and
- -
esLathe es nut wner of
calix Law does nut apply m ft with a of m tiony who builds or improves thereon, and
and
who contracts for such projects with acontrec,or(s)littnaed pursoantmihe Conmecwre'
License Law.
�-
❑lam exempt untlerSa. ,B &PCfar this maw
Owner e - - Dole
,
- f
WORKERS COMPENSATION DECLARATION
IIIemby vsfirm under penally of cepury on<of ted following dalunuons
r -
I have end w ll marnby eCm,ficam of
for by Section 3]00 Lao to ulf+fort f Works
Lamr
aeon as provided the
of the rom o
Code, forthe pesfom,ena of the
work forwhich this pemm ,s hes«d.
OI have and will meiWodefm
e Compensation Invun a re,.mod by Section
-
3]lXlof Nmr, for
e LaCode, far the perlormmme of the work for which this permit is issued.
'• '
My Workers o N tion Inst tt c er and Policy nommr art:'"
�n
Cameo �'x. Policy No.:
-_
CERTIFICATE OF EXEMPTION FROM WORKE
'
. COMPENSATION INSURANCE '
,(This uction needr,m mcompleted ifNepemdt ie foronehmdteddollars($100)
- '
on lased
v .i
- lecnify Nat in iheperformdnce of the wmkforwhich Nispemnis ipuedlshall
s
not employ tiny Person in any manner so ea m income subjarto ted Werkea' Compen-
• '
smian laws of Cali(omie. Das
-
,
Applicant
NOTICE TO APPLICANT: If, after making Nis Certificate of Exemption, you should
become smor,ly Ne Worker's Co ons of Ne Lbor Cade, yeti mon
..
.
us., this permit
forthwith cemPlY with such Provisions ar this pennir shell W darned revoked.
CONSTRUCTION LENDING AGENCY
+
O
I Mmby mTim Nat Nerc is v wr,aWcdm ]eMing agency rorthe perto�m oP
-
rot
Ne work for which Nis permit is issued (Sot. 309], Civ. CJ
.,
F.,
Lender: Name
.
(•(, i
Lenders Address ..
- -
W Q
I ttnify Nit I ha«reed Nis eppli«tion and sore Nit ane amve infonmtiw ia.
- - °i ` -
correct, l agree on comply with all city and county ordinances and store laws misting to
.
1' -
,,UO
building construction. and herobY memorize representatives of this; city m enter upon Ne
�.
above-ntemiwed property for inspection berprua.
W ,ey
agreem race indemnifyand keep hay Circ ofCupertino
.. .,
�' f•,)
esju in
liecmue,mcemwm, uind expenses which may in any way acemeadeinn said City
idCity
iy W
in conuquctmc of the gmming of this permit. I-
starting
- •-
F� IA
APPLICAdCT4tltfER WILL WITH AIA. NON POINT
.,
SOURCEREGULATIO
;.
�
'
`yam''• 'Cl �•
,Signawre ofA IUCD t mm Dam-,
- S IA OSI
thea u, - amremisooflelooranousmmerial
u tl flied by NC Cupertino ummpel Cad , CWP' a 9.12, and the Ha1N and SeFdy
Re -roofs , -
-
Cad Section 25533(.)?
Type of Roof
- Oyes ON.
"
Will future Wilding ceawhi<h;
'All .roofs, shall'be inspected prior to any roofing material being'
the appl¢ensoraup tuseeq,ip tarn
emit huntsman air contaminants as defined by theBay Area Air Quality Mocipment
installed: If: roof is installed without •first obtaining an inspection
❑Ya ❑No - y
I agree to'remove all new materials for inspection. Applicant
nds:and
uaert dNehaadwamateriax under chapter 695 Cali.
un ers
d will oinTT1' with all non point source regpulations.
Y Y Y D..v
I•
rtqunurenm of the
fomu Health & Safety Cade, Sections 25505' 25533 and 25536 1 understand Neuf Jen
WJd,ng does notcunenty have a tenant tat my responsb,hty to notify thus
`of No rcymrtments which mustm mn priori a of a Certificate of Occupancy.
On
-owrmrpraatnonaedagent
.'Dem
.Signature A- ic• Date
„
11
-
Ings to be Class "B" or better
OFFICE. :