00030051 CITY OF CUPERTINO "IT No. i--
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: b Nb �5
• BUILDING ADDRPSS: ' I�I r]^� INC• 1
•� 'afr� SANITARY NO. APPLICATION SUBMrITAL DATE
OW "JNA 253/V V CrGI��%-
G�fl Nie CONTROL#
PH()IQ�./fin ��3cam , CS 9ya%D 11_I A RRC 1111 EECTMN ,INI711R ! n �Z/ r/ IUL°ING PERMIT INFO
500 U L Y
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"Z LICENSED CONTRACTOR'S p DECLARATION
Z 0 I ion .Rrm Nn 1 3 ,yen l under mCh. 9(comm, Job Description
o N r provisions per erg
wiNSxlion]WOIafDivisionloNcBuaircuWRofaaiomCode.and mYlic � .I r
'ammurareew<rtml.
On a uun.e U,0
Gml,DECL
ARCHITECTS DEpublic lOt1
1 undcreWd my pWULWI be user u public mmrdE
a'e o UcenaN Pmfwi'ma
_,LL„ OWNER-BUILDER DECLARATION
L>, 1 herby,nim that I em exempt Bore the comrutoYs License Law for the
T C following mann.(Section 7031.3,Bull=%and PMeuiom Code:Any city a county
which requ permit on conecom,alar,improve,durolish,Or repair my IW[ene
�3 prior loiter mutance,tlm require,the applicant fineuch pamdt m file.eigoed.w<mm,t Sq. FI. Floor Area /,;,7 [ion
that he is licensed pmumt w Be,provisions Of Ba Conaa &.Licence law(Cluprer9 ` ,I-/• `M
(commercial,with Seedon]tnwer Divi.me 3 of the Entire.,and Not..im.COAnDe APN Number Occupancy Type
that he i.exempt Naefmm W the bait,for the alleged a monim Any vudmh n Of �O�a
Section 7031.5 by my applicant fa.prmul mbjaa the applican,In.civil pealry of
d mom thin fire hundred dollen($300).
.I L..he work,AM themocmnrcmplryee.withw.ge,m Neb sere mmpauaBue, Required Inspect ns
will do the work,AM the awc,urt I,..in,endee or ortcmd for late(Sm.]pit,tluineu
and Plofe,atoa Code:Or,Ccu mctm'.License law duet,not apply to en owner a
pmpcny who builda or impmu thereon,and who Eno such woh himmlf or through
his own employee.,povidrd Uw.inch impmaemems K ver imended a offered for
late.IL hewctcathc Wil dingaimpmvrm,nti.mrd Whin nail dorm emleuonua r jO
n-Wilder will here the borders of proving that he did not Wild or improve for,,he
pose of m1c.Y
❑I,As Owmr of N,property,am exclusively connacung with lianrod cOnvuwn to
common,the project IS..]Oe,,Boric.and PrefeaiOn Code:)The COmmum'.Li-
came law doe,nm apply to an owner of property who build&or imWovu Ncrmn,and
who contracts for such pojeca with.contnnor(l)licenmd punuanit to the CentractorI
License law.
❑l un exempt under Sec. .B&P C fm this won
Owner D,m
WORKER'S COMPENSATION DECLARATION
IhertbY artirm under penalty Of parlury one of the following
ded.n,ioa:
hereby
irm user penalty of Orjur,me oelf-slowing ortefsCompan-
tu provided fa by Sauon 3]00 of the labor Code,fm the pefforrame of the
Fl
o,, which ll pamilti.iaatl.
thaw and will odefinhnnrtei,rance film
Imumce,h recIhis cdby Wood.3?t,1 ofthe labor IC�de,for the parfom.ntt orthe wort fmmwbh�ircherN.is pamil n iuucd.
C.m`crh�l�HThmat�'�(rNC/ Polk Nano lro.n/SHK 3.�V
CERTIFICATE OF EKEMFIION FROM WORKERS'
COMPENSATION INSURANCE
(Thi..aim eecd not bemmpletcd dth. .it is fmonc hundred doll.n(SIN)
or Ica.)
I certify that in the pono.e of the work forwhich Ni.pemil is itmed.L Alan
nm employ my parace in any m.nea.o.s to bacon,oubject to the Workers'Cmnpn-
Am..law.of C.liromi..Dam
Applicant
NOTICE TO APPLICANT:If,after making Nil Certificate of Exemption,you should
become subject to the Workce,Compcnution provisions of the labor Code.ym most -
fonhwiVlcomply with such provision.ne Nil pamil.hall be domed invoked.
CONSTRUCTION LENDING AGENCY
Q I hereby elfin Nat there i.A comuncim lendin Agency for the prrfmOAmO of
Z = Ne work for which Nis .it i,....ext ISa.009],Co.C.)
Iendnea Name
> 1<Meis Addre.a
ts; 1 century thin 1 have mad do.ii,die,tion and man Nat the above information is
L z correct,,.gra m comply witb all city andcounty ordnance,end m n hews relating m
z building construction.and hereby sumodre representatives or this city to cmcr upon the
U above-memimad property to,inspection puryoncs.
La. F owe).grin to.a,indemnify and kap hamlets the City of Cupanino.gainst .
C U liebBme.,judgmcna,<ma And cxpcn.e.which on,in my way acne,again,laid City
y s in<onaqume Athc gronungaNiaprmn.
APPLICAN' IFIt)[RS'rANDSA eOMPLY WITH ALL NON T
U Z SOURC.
Sig^Wore of ppliu ont or 3�2 Date ✓��'
HAZARDOUS MATERIALS DISCLOSURE .
Will ml
the or future Wilding occup .tor,of handle b,rardous m.an.l -r ofs '
ex defines by the Cupertino Municipal Code,Chapter 9.12.W the Health and Safety Type of Roof
Code,Section 2333I(a)? yp
rl Tea
Will de.,hcant or future Wilding rccupant tum equipnam mdcvice,which All roofs shall be inspected prior to any roofing material being
enh hreardousair mmumma u defined by NArea Air Bay AAB Quaint,Management installed. If a roof is Installed without first obtaining an inspection
°°°'err? t� I a ree to re ve all new materials for inspection. Applicant
❑Tca g
understands ' d will co y with all non point source re ulations.
1 h,.e in e Ne n tires.m•,-,;a.nweimn,ena ewer I and x93 that
Glue - 9
ani.Health&S.relY user 2330.3,].5s 'ind 233#.I uMusund Wt if Ba
ofthem moment I cmrnnk Natoi myresponuomficitn 0 Bre ore{watt U(/
of the rtyuvemcm h - m iold, of•Cmrnn o Occu
Signature of ApkwvDate
Owner err euthorii D a
All roof coverings to be Class"B"or better
OFFICE