00050080 CITY OF CUPERTINO PERMIT NO.
t5un.uwcurvtstoNPERMIT CON T )TION: OO � �j )
DUILDING ADDRESS UB
: j� - �,v�tv�/TM�f pcsC•w• SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: �� ♦ �. -
A NAC CONTROL#
1 ARCHITECF[ENGINCER ��,J�� BOLDING PERMIT INFO '!
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LICENSED ended i dio,m ECLARATON
O = 1 hertbY.Kars that 1 w license ander pmviaiom of Chapter 9(commeneing Job Description
2to t•w wifulift on]000)efDiriaiwJofthe Bwin[ssand RofcuionsCodc,ad my license is
z a in urn more wGRtJ moi`/ /v l-s�✓.L/R<C ('/>f"/4�5G illine
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Llccnsc Claes lic.a
u�3 y Dnc Cwtracur �dL(��L+�et2-e4 d�/� �/G �y �.�.�..- .
I-=O ARCHITECTSDECLUtArTON LYS /
x v�a 5 I undersud mr plans"I be used u public mods � /'I�� ���jJ
a6c Licensed PmPosaiond / enw.aT!/ _ J` •n
It"-'•� OWNER-BUBlaER DECLARATION ,�]] �(T A�
i a I hereby.Tam Out 1 am ea<mm from the Contractors License law,for the (it7 `ij/�/ •✓ f/ !f T
t=❑ following reams.(Section 7031.5.Buaircsa.d Profession,Code:Any city or wumy
c.ww-" which mi,incs a permit m construct,alter,hi maac,demolish,or repair my structure5 m prim to is loon.nee,deo require,the apphsam forauch pamul to file.iigndeatement Sq. Ft. Floor Area aluation
that he is licensed pursuant to the provisions of de Contractors luate Law(CTuptec 9
(wimnencin{with Secdav]000)o(Diriaiwlef thcBmims ad Pmfeuinnseodelm APN Number - Occupancy
wt he IS exempt therefrom and we loris Tar the alleged[e[marse ption,Any violation ter P Y Type
Second 7011.5 by any applicantTor.permitudjecu thc.pplicant to.cirll penalty a(
wt mons than five hundred mast,($5oB). C/
❑l.esmvmeofthe propeny.ormyemployees with wages astheir aal[amnp[n..dw. Required I spections '
wiUdoth[wmk,.d the.trucmn is not imedd oroRcrd Tor We(Sim.7W,Business
and Pref"in.Cols:The Contractor's License Law alms ata apply 10 N caner a '
mommy who Wilda m improves throme,W who does such work himself m though
his own employ¢.,pmvidd that ouch imprenmmu K fid inu dal or oRemd for
salt.If,li..aer,the Wilding or imprercmmt I. within ane yevafcordd etion,the
owner-Wilder will have the Widen of mesio{that W did nm Wild or impure for pur-
pour of We.).
❑I,as owner or the property son cacluaiaely contracting with liccr of contractors t0
com.tt Ne Mjcct sec.7W,Bmlocn and Pmfeuiwa Cale:)The Conmctm's Li-
cense Law does not apply to ast owner of property who Wilda or improve.Verson.and
who wntncufor such prejecu with a contnetortal licensed pursuant to the Contactors
Litton law.
Alun Lexempt aw.
501. ,Bk PCfor this reason '
Owner Date .
WORKER'S COMPENSATION DEC AMTION
1 hereby.mrm under Many of ps jury ons of the following declai.tione: ..
'❑Ihsve and will maintdnaCenificauor Conwntmsalf-inmmfnr Worker's Compen- -
mim,as provided fm by Section 3700 of the LaWr Code,for the performance of the
work for which this prod,is i..trad,
❑I have ad will msinuin W.rus a Compensation Insurance.u regalrred by Section -
3700orthe fa Wr CWq for the performance of the work for whim his permit is issue.
Mr Whhea camp and lroWrKG
Caider: �' - Pad No:
aC RIIFICA OF EXEMPTION FROM OR S'
COMPENSATION INSURANCE
(This section nmA fid be wmpletd dNe pemtit is fortune hundred dollen(SI00)
lir lea.)
I testify shut in the padmmiance or the work for which did.pemtit is in ued,I shall
not employ any person in any manner to as to become subject o the Warrants'Compen-
sation laws a California.Dau
Applicant
NOTICE TO APPLICANT:IC after making this Certificate of Exemption,you should
hcotne aahjcct to the Worhea Compensation previsions of the Law,Code,You must
forthwith comply with such previsions in this permit shall W deemed sevokeal.
CONSTRUCTION LENDING AGENCY
0 I hereby affirm that them is a construction lending agency for performance a
the work for which this peimit is issued(Sec.3091,Cl,C.)
Lenders Name I•
y' } Ledo,Address
W Fz I certify dust 1 ham read this aplAxi ion and auu that the.bore information is
0. z correct I agree to comply with all city and county ordimmi,s ad nut.laws mining to
U O Wildin......do..and hcmby authmim reprt¢nmiver of this cqu.enter upon the
above-mentioned pmpeny for Inspection purfi
(We)agree to save,indemnify aid kesp harmina the City of Cupertino agalmt
Babihun.jd{menu,cmrsand eapamea which may in any w.y.ce%is.,wmt,aid City
} W in conaequ[nee of the granting of Nis Ixmd.
FAPP;xxMruNDF.RSrANDS'AND WILL COMPLY WITH At.[.NON METy
U S .NCC REG uixtiaNS.
S' n o . uV u
a'
n r OUS MATERIALS DISCLOSURE
Will the applicant or Future Wording wcupnv nam or handle haxudoua material Re-roofs
as defuse by the Cupertino Municipal Code,Chapter 9.12,W Ne Irulth and Safety
Code.Section 2S512pp Type of Roof
❑Yss ❑No
Will the.pplicam or future building occupant me rquipmem air devices which All roofs shall be inspected prior to any roofing material being
midh.ardmis ab containbunu.a define by the Bay Ansa Air Quit,Management installed. If a roof is installed without first obtaining an inspection
❑Yea ❑No
I agree to remove all new materials for inspection. Applicant
I hive read the hasardo s moterida mguinmrnu under Chapser 6.95 of the Cali- understands and will comply with all non point source regulations.
Famous Health B Safety Cod,Smiom 25505,]5533 ad 2555x.1 uderstuA Nu if the
hail g - fid 3JLLyy�pp,, •union,that it is MY naponailuddy m notify the occupant
f r
Pico mciprivr tai' f.Ccniti<.tc nfpr pgficy. s
�J/ra�R ioti Signature of Applicant • Date
Tor wt xd.gem � D� '
All roof coverings to be Class"B"or better
OFFICE
a i Asia