00040062OFFICE
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
CONTRACTOR INFORMATION:
PERMIT NO.
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HUIhDING ADORP,Sl:
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SANITARYNO.
APPLICATION SUBMITTAL DATE
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OWNER'S
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PHONr.:
ARCIIITECTENGIN ER
RULDING PERMIT INFO
to to00
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LICENSED CONTRACTOR'S DECLARATION
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1 hereby affirm that I w licensed under provision, of cloister 9 Rormmrcing
Job Description
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wSection7000)ofDivisimlofte, Rasincas and Profrnion,Cede my littnu is
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in full force and eRe _
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are C.nu•cuu
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ARCNnF,LTS DECLARATON
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I understood my pram shall W used as public nocords
to
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OWNER-11MDER DECLARATION
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1 hereby affirm that 1 em exempt from the Contractor's Ucenso law for the
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following reason. (Section 7031.5, Rmircw and Pot iem Code: Any city Or county
S Ft. Floor Area
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Valuation YQ
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which r[quiml • Permit m conawn, alar, improve, demolish, ar pan an, lwcturt
primtous theapplicant foe coonrasme wicessigned a
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slcensed Palwsquirts
Poe,g
ache ContracmM1LicmalAw(CCager9
he eking
(cotha
oo Sm...
(commencing he is elewilt Sector ofprovisions imi 3 di eas mCede)m
t•1 he is terefrom ter basis far
AP% NUae�f
Occupancy Type
and violation of
andorDivisionJu/teece! c.andPA.,
Ibc st, da ,licam n.. civil
3l2i b far wbjau re, applicant toacivil pemlry of
Sector ]WI Sbr any•red
a.�
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doll
nm mom Nan Eve hundred dollen (5300).
($5M).
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Required Inspections
❑ 1.asawte,,.rtermpenr,amremDloyrc,wtw.geaasde,i,solewrrtpcm•ton,
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will do the work. and re structure is rot intended.roffned for side (Sm. 7W Rminms
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add Profulimta Code: Tne Counselor, Liver. Use duel nm apply la an owrc, a
terror, and who does such wmk himself a tlwugh
ny, who builds or vided
d menu art Out intended m for
his o rcs, provided to such i
his own
plkrtd
oweve en, sa
ule.ILhower rte
buildinguren
wennnnrildori
,
of prmcntiudd
with
r-W ildcr will have Ito burden of proven{ that to did nm W ild m impose (or pur-
improve
pou.f
�-a� )
D 1, u owrcr or Ire Pm0•rtY. am esduaHely c.nvuly wit littnoed conu•nme m
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, the and Pr on, Code:)MCmmclon, Li,
cent Cl toes not
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appl(Smy
to weer of whobui thereon, aM
c use law does not apply m as owner of property wce build• or Impro
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such prolecu wit scanvaeter(a)Ikeased punumtmthe Contracts',
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LiccA.mm,far
Littnw few.
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D lamexempunder Sac. ,RiPCfortismawn
,
Owrcr Date
WORKERS COMPENSATION DECIARATION
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I hl ctry afire under penalty of erjur, me, of tC following helantlom;
❑ I h rvc m l will maimun • Ccnifcau of Consrn to wl6imvrt far Worker'I Csnpen-
wlion, u provided fm by Section 3700 of the Labor Code, fm the pertommce of the
work for which Thi, permit is mis.d.
D 1 have and will m.iown WskCB Compemm.. Imur•nce, u required by Section
'
37M.(the Labor Code, for the perforr ouram of Ito .,it for which Thi, perms, is inued.
My Workaay�ypQyaylpyl iurtlpoP earn Pod Nligq rrrSR'.ic !J6
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cower 2rKJ6/'4M/ �1�b /
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CERTIFICATEOFEK PION FROM WORKERS'
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COMPENSATION INSURANCE
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(nil section recd Out W completed d1hC Permit is foronrhundnd dNIN (3100)
Or Imo.)
I cer ifY W, in the paramos mof the work for which this pamdt i, issued., shill
out employ any person in any manner an as to Iecone, subject to the Wmkera' Compen-
action laws of Cmrmnu. Dau
Applicant
NOTICE TO APPLICAN'I1 If. the, maker{ Nil CeniGene of Esrmption, you should
hmnre wbiau in Ne wok x Cmnpen ation provision, of he, labor Cade, You most
-
foMwit Comply wit such prt'siom or to Permit bill[ W domed revoked.
.
CONSTRUCTION LENDING AGENCY
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I hertbr aRnn lha, ton it • commotion lending agency for the p rf.e.f
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the work for which his permit is issued (Sec. 3W7, Civ. C.)
undrrs Name
lenders Addreu
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I unify bad 1 have read his application and awe that tic above information it
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correct. I Mocc to comply wish all city and county Ordinances and state laws telning to
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building cmamrNon. and herby sullen. mpecroutom of this city to enter upon the
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above-mentioned property for impecton purposes.
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(We) •gree, to asK. Indemnify and keep harmlm the City of Cupertino ayrmt
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liabilities judgment, c land ea tea which rmYinany wry •ame ag tun,. City
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in <onuquerceoft nti
AN 1 F IITII AL1. ' -PoI r
&1W"1I,.IC0:MpIY1
SOURCE 1 A Irl'
INN /
5' ApplicanuCentractm Date
J �VTOh/V CC 1
el HAZARDOUS MATE RIALS IS
Re-roofs
Wing e, ooh
future Wilding occupe.Chapt nareo,a huuth Safety
he Cupertino
as dcfirctl by the Cupertino MuNcipal Carr. Christer 9.12, and Ik Huth and Safety
and
Code, sectmtu9z(.r. �
Type of Roof
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Will the applicant or future building occupant use equipmentor device which
IhawdouI ab conclmnams as defined by to Ray Ana AU Qudlry Manycmem
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All roofs shall be inspected prior to any roofing material being
installed. If a roof is Installed without first obtaining an inspection
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❑Tea o
I a ree to remove all new materials for inspection. Applicant
h ve wnu,I.nyoinmcnuundcr 6T ��;
un erstands and will comply with all non point source regulations.
Car
Ca
tomo Hctlt 5 n C A05, 25 9 W 2594. I den d stn if to
buildiry rat L ityrtapomi ili aif pmI
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f tot r t ye pf pLpyy
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Signature of Applicant Date
ter or Magem .. Dam
All roof coverings to be Class "B" or better
OFFICE