00050086 cynroo-cvPERTINo PERMIT ONTRA TOAINFORt A IO N OTO aq T) $ 1o0
BUILDING DIVISION C g
BUILDING ADDRESS: OOOZOOB t -
ID -t is . D N^Zfl g NITARY NO, APPLICATI/DN gUO ITA/L DATE
OWNS 'S NAME: � \G /1 �[ O V
V I •g-��C! NIC - CONTIpt
DNio a 3- 9206
AS
B LII N.•PI?IIMIT.IN�O
/I°taco � � ' k b It✓:nc N fao<a4f<�
hz
' m LICENSED CONTRACTOR'S DECLARATION '
O z..p 1 hcmbY affire Nal I un licensed under provisions of Chapter 9(commencing .Job Description
F=C
to{ with Sauon7M)orDivisio 3 fN B..,..a Prof,vioas Sandmylimnseis /�� o +
zxZ in hall form and eR�e , , mC_l- , T� /l^T./- �J
Limine close Lic.N
3 a y Dne Connector _ �"
I-u.O g ARCHITECTS DECLARATION - -'•
1 Understand!Understvmy plana shall W used as public record.
n n. Licensed Pmfeasloand - -
S_ OWNER-BURDE oD'ECLARATION
1 hereby affirm that I em esempr f the Comrectoes License Law for the e s
❑ following reawn.(Section 703 L5,Business and Profesonew code:My city os county
u 3$ whim requires.pewit m camwc6 allen impm s,dmUUB0,or roper any emnwre S FI. Floor Area
priormib issuance,also rtquireatW applicant forauch prmutm Ne a.iBned statement S� `Z Valuation in the provimUs Of to Caroni License Law,(Chaprer9 VC /�O O�
(commancieg with Section 7000).f Division 3 of,W Bull.and Profeuiom Code)cur
that W is eampr therefrom sad me basis for Ne alleged exemption.Any violation of �` AP1Y. LMb 7 Q - Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicant 10 a civil penalty of �J '' // CCJJ
not come man five hundred dollars(5500). '
❑Loan..,ernrmeprop.ny.mint.mpinyee.wNw.ge.asmeirmlecmmpenn,den. Required Inspections.
n will do Ne work,and Neewcwre is men intended m.himut for.1.(See 7844,Boom.. t
and Professions Cade:The Convenor's Lianas Law does nor apply to an owner of '
property who Wilds or impaves Nerwn,sed who does such work himself a through +
his own employers,provided But such improvements me and intended a offered for
sm.If.however Nc Wilding or improvemest1.Kid whourne moofe mundon.the
wnenWilder
will hare the burden of proving that he did not Wild or improve for Pur-
Panawe.).
❑1,as owner of me Property,nnn eacl.u.)y conuaning wine licensed contactors to
eonstseet the project(Sec.7044,Business and Profession.Code:)The Congaeors Li.
came law does Out apply In an owner of prepeny who Wilds or improvra Norton,aad
wM ourtmemm mch p ejecta with acomrscw(.)licensed pursuant m the,Contractors
License Law.
❑fameminni eder Sec. ,B6:PCfm Nis reaan
Owner Data
WORKER'S COMPENSATION DECLARATION �.
1 Wreby effiw under peulry of perjury one of Be following declmmdom: - 6l
40011 have and will maintain a Ceniricate ofComent an self-insure for Workers Couper.
.
union, Provided
(pe by
Section 3]00 of the Code,fm the perfomunee of the
r pr
work. which ee,permit is issued. '
❑1 have end will maintain Worhrs Compensation Insurance,as required by Section - -
3700 of be,Labor Cod,far led perfowenee of the work for which this Forms,is issued.
My Workers Compewtim Insurance easier and Policy number art: _
Carrier: Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS' - -
COMPENSATIONINSURANCE'
(This union need nm be comPleed tribe permit is forms,hundred"Inas($100)
I comfy inn in tha pefomutwe olid.wink forwhich this pnmit is jamad,I"I v
int employ any perms n any money so u m Wwme wbjat a me Workers Compere
action laws aa,pine
ApPI cant dr �.
W,. PLICA ,afmr melting Nn Cenificdm of Exampt�ion.you should
become wbjano Ne Workds Comp urambe provisions of 1W Labor Cade,you mum
,roMwiN comply with such provisions Or Nis Permit mail W domed revoked,'
NSTRUC ION LENDING AGENCY
Q COIhereby ofBwnn Brame is a canstmnth
lon leading agency for e peffmmince of
= Ne work for which this Permit Is issued(Sec.3097,Civ.C.)
Lenders Name
(� "j Leader.Addres.
Rl Q I unify that I have rad this application and gas Net the above infomwlion is
coven.I agree to eari wit ell city and,county aminunce.andewe laws reading m
building comualim,and hereby smhod.ramesemative.oRhis city to enter upon Ne !
V 0 above-mentioned property far Inspection purposes. m
tis F (We)agree 0 Live,indemnify and kap annulus be City of Cupenino agaia, '
O C.) liabilities,judgments,corse and expenses which may in any way mane against mid City
Win'on
ugacnce of a granting of Nis pewit'
0.
APPI.ICA ,ERT N AND WILL COMPLY WITH ALL NON-MINT
t..1 � SOUR AT, S a/ T
Sn re arAppincan✓Conumta. b'%'/`Z /se
HAZAR000S MATERIALS DISCLOSURE v
Will But applicmt of future Wilding occupant etomor handle hmadoue maunel Re-roofs'
Is defined by the Cupertino Municipal Code,Coupon 9.12,W the Health and Safety -
Cade,Section 25532(.)+ Type of Roof
❑Yes ON. '
Will doapplicant orfuture WRding occupied aaequipment ordev;ceewhich All roofs shall be inspected prior to any roofing material being
:rut heaadoua air conuminats as dented by tha Bay Ares A'n t]ualiry Maagemem installed. If a roof is installed without first obtaining an inspection
uinT
❑Yea 0 N I agree to remove all new materials for inspection.. Applicant
io I haviond the haarMms mmerials mluirtmema under Chapter 6.95 of the Cop .'understands and'will'comply with all,non point source regulations.
fmrua Halm Ar Sifry C ,Sections 25505,25533 and 25534.1 understand than if the '
Wildingdoes vc on
pq it is my uspsibiliry m neify the contracts
of the repo a ich til 'oraua.nceofacraificamofCcup.ncy.
O Non edneem Daa
i/ �S^may& Signature of Applicant Date'
All roof coverings to be Class"B"or better' "
OFFICE
PERMITNOP.
H.CXNO PERMIT 0ljoa00
IRXDTITGA
SANITARY NO. APPLICA IO SUBMITTALDATE
t,��,,. NK z—its- �o
OWNER'SNAME: . ,
,. NIC CONTROLp
DNL�5o3'
ARCHITECT/ENGINEER R111.OIN0`,17LRM1'ry .FO
�
0 ���nw� �. al vl n►r� Rssfl�r
Nz
r N Z LICBNSED CONTRACT'OR'S DECLARATION '
I hmeby efirme dust 1 are licensed under previsions of ChePtn 9(mWeancing - Job Description _
,Z4 with with Suction 7I)W)ofDivision 3 often Busirmssad Hmfeaeiom Code.and my license is "
^�'oia in full farce and cR«I. '
m U Liam Class Lic.Mk—
r V f rtlA/ 1 y�.[u�'w�t ,w ���/l�r p'Q Ir(���kg �{L..._
E:8-6
E`O N Dem ARCH ECTS DECLARATION �rtN�RCv7� fy !II l'Tg_V,V•v,LV I-O�T—�Ill• 1A s / 1
y OWNER-BUILDER DECLARATION
C Z< I hereby aMirm Nal I an evempr from the Cont emees License law for that
$F Q following rtason(Section M31.5,Business and Pmfaaiom Cade:Any city or county -
a m winch mpiva a permit to mrseme.alum,improve,demolish m rcpalr any runa'tweSq. F[. Floor Area Valuation'
prim su
to its isance,alreq
so uires the Wittier,for coach permit
h to file a signed aummm
c
drawls li«nuA punvant to Ne Previaiols of the Contrsstofe License taw(Chalgn9 �
(commcndeg with Section 7WD)of Division 3 ofthe BualtR.0 and Profession.Code)w APN Number Occu ane app
that he is europt c ancrmm and the basis for the alleged co myron.Any violation of /'}. Y
Section 70313 by any applicant fora permit e.bjecu the Wheano e civil W,.f 7 •
ped come Nan five hurdred dolbus(SSW).
l,as.w«ro(the preprnY•wmy employ«.with wageemdsirwle compeaaion, egalred Inspections
'wW do Newwk,Co th Tire CireiatsotinLt. Lin,ddfma 10y...mon,.
=nal Profeuiom Code:The,.actors.ands taw docs eta apply 1.lf owner or
his o nY who build,w impe.vdr ebneon.W who docs inch work d d or of Nre.yx
his own employees podded tine such impo«trcnu an,nm iouMed o offered for
vis If,hmvewz Ne building ur improvement u real within one yeam im rave(i npdre
r-
owner-Wilda will have the burden of provint Nn he did not build w improve(m par- /�
pole riddle.), 6 t
,❑1,..core of Ne property.em exclusively covuecung with licenred conv«mn m - es
construct 0se poject(S«.7DN,Business oral Profeuions Cade:)lite Contractors Li- /
t cense Law is f ret applyje ts owed of psesms cob Wilds or improves Raeon.and O
whoconvansfm such Projects withaconuactor(.)licensed Wrwanluthe Contractors D
L]
. 1 taw.
❑tart exempurdcr5«. .BA PCfea Nis rtaaon
Owner De
WORKER'S COMPENSATION DECLARATION '
-1 heral affirm under pmdly or perjury o«of the following decluvliom:
l have and wall ow,ouin a Certificate ofconsent to self-insurt fm WmkeraC.mpen-
who,
u provided fm Z=on 3200 of the Labor Cade,for Ile performance of the
work for which this pored,is istrool
Q 1 have and will maintains Weaker.Compenution Insure«e,u raquiwl by Section '
3700.(the Labor Code,for the pe foxmaase of de:weak for which this permit is wood.
Workers cmepeoses.Imran«carder W Policy number are
5iCamer,. Policy No:
CERTHRCATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
('Ibis section read!not be completed ifehe peemir is for.ne hundred Mi.(SIM)
or less.) 1
Loy any that in theperfonnarnce ofthe..it for which this the we ias.M,l thdl D
ploy anyp aym ase to recon,abj«tbNe W.
"°"`` APR 1 2 2000
N APp ANTI If,a n melting Nie Cesimes o th En mpdov,you should
beer subject m dse Workers Compaadon previsions or Ne IaWr Cade,you must -
g on iN comply with each gavwons or Nis permit shell W d«med revoked. - -
-
CONSTRUCTION LENDING AGENCY �t
•O.Q IherebY� m
rmthatthemisaconetetlonlerdingagencyfortmBl
heperforme
performance
71 Ne work for which this inmil is issued(Sec.3097.Civ.C.)
Fy Lenders Name '
p, ? Landers Address
Lal 0 1 unify that I have with
this.ppm coon and buts that ed above information is D r•5 p
a macs I agar to comply here dl city aha county mdwnm red.we i laws rtlaing ro I'I(VnU u '�LLj
z buildlbecmewNon,and for byeuthorissrposes,representatives of thiscily menu,upon the
V .above-memiobed propny for inspection Purposes
Lz F (We)egm I.save,indemnify and kucP hatmlas the City of Cupenin.egainn t
O V libbarna,judgmenu.cauandeapeneawhichmeyinanYwaY«cme.ganatsaid City APR 12 LOGO
>y W no=0.Usegeasingof Nis,conn.
N(.1t APPLIC. TUNDERSTANDSAND WILLCOMPLY WITHALL NON MINTGUL + 66APPIicarmCo ,tem, // - L]yHAZARDOUS MATERIALS DISCLOSUREheri'licam.,fumrt Wilding reempanulorem handle hued...mauri=1 Re-roofs
the Cupertino Municipal Cade,Chapter 9.12,and the'H«Ith and Safety
.2553xa)7 - Type of Roof . .
QYa i C2 No -
Will the applicant or form Wilding occupant use equipment devices which All roofs shall be inspected prior to any roofing material being
emit hazardous dr couraminanu es defined by the Bay Area Air Quality Management installed. If•a roof is installed without first obtainingan inspection .
0 Yes MIS. I aree to remove all new materials for inspection.. Applicant
(leve tad Ne harudwxnaudW lryuirttttenna under Chapmr 6.95 ror the Cali- u❑ erstands,and will comply,with all non point source regulations.
Tom Hce1N&Sefny Cade,Sections 25505,25513 and 25536.1.ndemund Net if Ne
Wrich onsmese ntlyheviceunanl,the it is my rotpontibility unutify ted occupant ti '
of da, 'rc in t pnorl.issumce.f=Cerifieem n(Oc open
/ Signature of Applicant Date
ror u ods Bem 0 e - _,
- All roof coverings to be Class"B"or better
OFFICE ,.