00040053 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0 Ob��
BUILDING ADDRE S: /J
rug 3�� /O/ ;1 A41eaa _5ere z �'« SA ITARV NO. APPLICATION SUBMITTAL DA'I
OWNS ' NAME �a `fY r/Ci ZI�L/�N /i?� `;,t--/0—03
`r�� ` �QG`.�/�� / ^f ��/}/[f NIC CONTROLk
AIML PHON.",: .5— 725--o3JC/ 6J7Z 'V ❑
ARCHITECDENGINEER BULGING PERMIT INFO
006
108
�m-
FzC
p0N 1 hneby affnn�sEDmCONTR�ACnder PPrDECmix Of CCOONptr 9P«mttmrleerig Job Description
F_t-w wiNSation]WO)ofDivisim3ofdx Busi='milliner arcade.And license is
<Y E LicA (Otte and eRe
Y� Lesm Ca con 6.� 2f/
w n a Dem Conor;public
C u.O I ARCHrMCI'S DECLARATION /
W� I undentaad my plans sIW 1 bruised as public wards
u.L 1Jmmed PIOfe.i seal
OWNER-BUBAER DECLARATION
1 hereby.flim,that I em exempt from the CO-Iramr.License Law for the
E ❑ following reason.(Section]031.5.Business and Profeniom Code:Any city a county
K— whiN"Wrim a permit m cambecr alter,improve.demolish,«repair any structure
d a_ S Ft. Floor Area - Valuation
pdamslits cenenca sisorn 1.the the proviu applicant for mchperl,to Liceat Law(ausemem q' �� O J
that he min licensed purnunt ro the of Disiomof the Coneano's li pene law(,Topa 9 —/
that
he'smgwiths«tiromanddo, iasiii for ofdue gmlexempton.Aniomcndc)Of - APN Number -Occupancy Type
that io i.exempt therefrom and Ne buss for the subjects
shed exemption.Any violation of 3 l 9 O8 OOa c Y YP
Section than
l S by my Applicant f«a pemdt subjects the applicant w e civil penalty of Cl J
pt mom Nan f ire hmdred dollen($500).
I•mawnaofthepropeny,amyanplayaawimwage mweiranleeYmpat on. Required Inspections
will do New«k.aM the avmwrcumtinrcnded«oRaed for ask(Sa.]011.Busimrs
and ery ;2
pmpertY nA Code:The Conuacmr's Licence,law does not apply to an ower of
who Wilds or improve thereon,and who does such work,himself«through .
his own employes,Provided Nat such imporeme nu are not intended Or oRaed for
.ala If,however the building or impovemcm is sold within tine year of a mplaion,the
.1builder will have the burden a proving the W did not Wild Or improve for par- ,
pmeofsale.).
co I,u owner of the property,,R exclusively cweoting with Baneatl wmctor's m
censwn the es not(Ser.]Dna,owner
of
sed Profession Wi Cade:)The Canvorors anared cense law does not men
m is owner of pmpemy who Wilde ti improves Con rac and /
who seLatz for such polau withaconvomHOliunmd pursuantmted ConmclWs (/
License law. �Q
I am exempt un .B At PC fa Nis/t fwon
Owns Dam WORKER S COMPENSATION DECLARATION
I Well,affmn under pendry of perjury cone of the following dolatetiom:
❑1 have end W III maintain aCertifcam ofComem to ulNinsare foe Wodere Compen-
titian,as provided for by Section 3700 of the Labor Code,for In,perfmmtame oldie
work for which this permit is issued.
❑1 have AM will maintain Wodrers Compenxatioo Insurance,as;required by Section
37WO the laWrC ,Ica perform of the work f«whicM1 Nis permit is iswM.
My a Co mat an, nand Policy
Cartier. Policy No.
CERTIFICATE OP EMPDON FROM WORKERS'
COMPENSATION INSURANCE
(This motion oned!ns W wmplaedJthe penin is f«me hunioed MI.15100)
Iamity dotinthe arfomumcoath. for which Nis thewisissued,lsail,
rot employ any person s
e
n iia any manor o as m become
ome xubjat to dm Wahoa'Compere
sairin Lewy of California.Dan
ApphOTIC l
NOTICE TO APPLICANT:If,aha making this
ovisio sof of Exemption,yon should
hecmme subject to Ne Workers Compensation its provisions of the lab«Cade,you must '
foMwith wmPIY with such provisions or this pmdt dull be darted jcvoked.
CONSTRUCTION LENDING AGENCY
0 Q I battery arm that them is a construction lending agency for the Perfomuncea
"tea- the work for which this permit is issuM Sm,3W7,Civ.C.)
t.., Lenders Nave
> Leaders Address -
L 0 1 certify that I have mad this application and awe Out the above information is
•= Z e amcL I ague to comply with dl city and county ordinances and moon laws oekung to
V O building constmcdan,and beery authorize representatives of this city to enter upon the
above-mentioned popery,for inspecuan int"...
La. t—' (We)agree to save,indemnify and kap harmless the City of Cupertino against
O L.J e.rl4ues.judgments.crisis and expenses which may in my way Accre.gainst said City
} W in mmuortueoe ofthe granting of this permit.
wFi 6th APPLICANT UNEP D '
ANDS ANLLCOMPhV WIfH ALL.NON-MINI'
p, SOURCERLC A'f1D 1.
Sigmmre of ApplicanUConeactor / Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding acupam store«M1andle hmardaus matmaj Re-roofs
as deGmd by the Cupertino Municipal Code,Chapter 9.12,AM Ne Hoorn and Safety
Cade,Section 25532(.)P / Type of Roof
❑V<s o
Will the applicant or future Wilding acupmt use equipment or&vics which All,roofs shall be inspected prior to any roofing material being
"er ouss cw=in.nts. &fimdbyd B=YAra.AirweftyManage . installed. If a roof is Installed without first obtaining an inspection
via]
❑Yea � I agree to remove all new materials for inspection. Applicant
I hee mall the laccadaas makd,lsmouiremens ander Chp.6,95 of tine Cali. understan d will omply with all non point source regulations.
frim-Health&safety C dam 25505,25533 end 2553x,l mdssund Wt if the
Wilding dos mac hevcamnenl,, �°�y gy�responsibility to notify occupant
Of the on]ircme hichon r n«Ci'�r afa Cemficat f upend
TT �� Signature of Applicant Date
neo euthoneedegent Dam
All roof coverings to be Class 'B•'or better
OFFICE