00040108 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0004 ,0109
BUILDINGGADDR^EESS: //��// _� n LI�I'�] g1a /� /I
/05t,3 CrLe.-! t-it /` 1" f7�1r'10�•✓ ( QNST/T UGTpl� SANRARYNO APPLC NSUBQ ALDATE
OW 'S NAM Z:y N/C CONTROLN
PHONE: p/Y/_� I��/a Il•- tYQINO
1 ARCHITECT/ENGINEER ( • �OBULGING PERMIT INFO
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I_ y LICENSED CONTRACTOR'S DECLARATION
oz v,O I hereby affirm Ihn I am licensed under Provisions of Chapter 9(commencing Job Description
F,:t W with Section 70(0)of Division Sof the Due.,.Tend Pefeviov Cade,and my been.is
=uw� in Nil force and street �O'J Z.2.2=
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C Linea Lit.N JJ Z.2. � P v a.-
ic H Dau Conuac lYQAL V.
F ilt O a ARCHITECTS DECLARATION
f -1 1 undeTnand my plans shall W used as public r«ords
`2
ED a o O Licensed Pedreummil
¢S^_ OWNER-BUILDER DECLARATION
k-z< - 1 heathy.flim,that 1 am exempt from the Contractors License Law for the
following mase,.(Section 7031.3,Buri«la and Proloid.Code:Any city«county
41 m which,quires a permit l0 cmuwm,alter.imPrvvc,denwliah,or rtpur NY swcturc
d a_ Sq. Ft. FI r A a VdLyation
prim m its issuance,also rtquirts the apPB<ant f«such peanut m rile ui8nnd auamem /JC
Nath ncia nwi pSman 7")of sim3 f eBusi ds Proflaw(Ch )w �y 000 --
(comatis'cgn"tSecuan71100)ofDiou,farmeaeegdrxuandProfeuvilate. I P N r Occupancy Type
Sul io is exempt My Allith and rhe avis for the alleged!<x limt t.Any it penalty
of /� yzs.yry P Y YP
Section,than ve any applinns ran•4)(3). subjects the appliuvt to a civil peerulry m CLQ/
pof mart Nen five bandied doll.,(130111.
Lnmamrarthepmperty,mmym,pay«.w;thwat,«uthc"vaolecompenurim, Required Inspections
anal Bothe work,ands: her Comet not imcndnd LaReadfmtalc(Sec.1.an,Buaincu
aro erafeuimu Cade:The Coruamor'a License taw docs mor apply to lf uv«r gh
his o nY empl Wilda or imPmva thereon,aro who don such want dee or of Sardinia
Ns own employees,Boding that such i entis mmu as nm intended a oRcmO for
We.If,howear,the Wil ding rimpmamen,is Wild withint y«rofcomx.far,the
wa.f l lo«will N«the burden of proving Nat he did nm Wild m improve fm qac-
qua of swarte
1,v t me p of ct Se.7paupers,,f exclusively contracting with licensedThC contractormmuctue,U.construct de.Put (Sec.708gwner laandry wine
Code)Truwl dee lor.Li-
cense law dens r such
apply ro an owner of pmpary wce Wilds or improves Contin.aro
whence Low. such projecu with aconTamorfy licensed pursuant.Ne C.nrncmrs
Licence law.
❑lson,exempt under S«. .BhPGfor This reason
Owner
WO under S COMPENSATION DECLAMwing
1 hcrtby elfirm under penalty of perjury one of The following dcclvetioru:
❑I hevesndwillmeintunaCeniilnte of Consenuoulf-inmrefer Workers Compsn.
cation,to;provided fee by Section 3700 of The Labor Code.for the performer«of Ne v�
..it for which this pared,is issued.
❑1 have and will maintain Water's Compensation Insurance.v required by Section
3700a1fthe Ia Wr Cade,for du perromnvue of The words fm which This pcmnit is issued.
My
CartWieumrker's Ypn lnua sand Pole'y nu CJ
Polk
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This arclim«d not he completed if the postai is f«o«huedz W"burs(Sim)
or Ivs.)
I Tend,Sul in de perfomunceof rhe wml for which Thispemut is issued.l shall
PDT employ any Person in any menrcr se aala c O rte Wmkera'Compen-
cationlawsof j�Daty�=.T rc
AppliaanT �2Y�. �0
NOTICE TO APPLICANT.If,ifar making This Certificate of Exemption,you dreadd
become subject to the Workers Compensation ravaimal of the Labor Cade,yen man
forthwith comply with such provisions or This Permit ahol be deemed revoked.
CONSTRUCTION LENDING AGENCY
Q I hereby affirm thas mem is a conawNon lending.gency for the per...of '
the work for which Nis pemel is issued(Sec.3097,Civ,C.)
lander.Nome
a ;o- lenders Address
(,y 0 I certify Than have reed This application and stale Thal The above information is
correct,I ague to comply with all city and county ordinances and state laws relating to
z building conawcd.n,and hereby sumer..,apreunaliv«of this city,.enter upon the
C.7 0 above-memirncd property to,inspection pmple.c.
W Ey (We)agree to la«,indemnify and k«p harmless Ne City of Cupertino,ega tom
V liablliees,jWgmems.c«ta and expenses which may in say Ply...g oat laid City
�., W in consequence of The parent,of this Permit.
'r 0. APPLICA OF STANDS 4Nil WILL COMPLY WITH ALL NON-POI -
V z SOURC' ! ,UI ONS.
�/ 1-793- 64
Signenue of Applican Cnmractm r
HAZARDOUS MATERIALS DISCLOSURE �-
WTIISeeCtiperm.fMuni ipal Comcupattsroaar handle Health amaterim a-rOOfK 5
v deEmd by the Cupertino Municipal Code.Chapter 9.12.and The Health ave Safety
Code,Section0Yeasss3x.Y! Type of Roof
❑Yea
Will The applicant or future Wading eacupaut sea equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hazardous setamiva v
r conndefined by the Bay Area a
Ah Quality Management installed. If a roof is Installed without first obtaining an inspection
°`"""'
oYe. tdN. P PP I agree to remove all new materials for inspection. Applicant
I have wad the haaarcim.materials nation...Tender Chapter 6.95 of the Cali. understands and will comply with all non point source regulations.
formal AI nal Health R Safety Code,Seceom 25505,25333 and 25530.1 undersand that if the -
F IT Id nm c.ra ly baccate,m,thnirismy acpon' .nWfy amvpant
i of N 'cM1 mu prior a ire«nce e C Tceta o open
a Signature of Applicant Date
mer or.0 nzeda - '
All roof coverings to be Class"B"or better
70822. OFFICE