00090043 C>BUILDf Gr DIVISION CONTRACTOR INFORMATION: PERMRNO.
PERMIT
BUILDINGADDRESS: ///
/n�� ) / SANITARY NO. APPLICATION SURMITTALDATE
OG /Vy� ,Y A fi4onCE C W M P A N Y 00090043
owNER'. AyB/U' 2 CrJ?/tf I f)- S�bn C A�>>✓/
NIC coNTROL»
one- 1712 T NE AVE ❑ 09/1. ]./2000
6 �— Sas Taus n. . iqIj
12/ P
RCHITECT/I:.-GINEER BULDING PERMIT INFO
00
(408)293-4717
G
ac
LICENSED CONTRACTOR'S DECLARATION
Z
1 henbr.M.that I.licensed trader provision of Chapter 9(commencing Job Description
m Nil F=F� wiN Smforce
andiI
00)afDiviswnJoftbe Busima..nd Profmima Code,aud mYlimneis �s��
30.LL^ Licenm class eJ Lic.N—i.f[ ,II....(( L� •C OO
D.tc--Q Cmwctpr T
F u C g ARCHGE S WCLAOnON
5 y 1 understandmy plans Nall he used u public records
ori Idsnsed Prof..most
OWNER-BUILDER DECLARATION'
t?x I hereby aRrm But 1.exempt from the Conscience.License law for the
F A following lesson.(Section 7031.5.Business end Pmfcasima Cade:Any city or county
3 which requires a permit in mrstruct,alter,improve,demdlish,or repair my structure, S Ft. Floor Area Valuation
prior no its issuance,almrequims the applicant for such permit m file a signed statement Li r Q
Net he is licemd pursuant 1.Use pmvid.m of Ne Co. . &.License Lis.(Ch.gv9
(e°mmeneingsaid,s,mn70W)°fDivision3°f NeBmiemsandPmranimnemc)m ApN Number OccupancyTy��955
cast he is exempt therefrom and the basis for Ne alleged exemption.Any violation a /`
Section 7031.3 by any applicant fors permit mbjects that applicant to.civil penalty of X J
an more Nan five hundred doll.(5500). p rsR
❑i.0 wear or Ne proKnY.wmy cmgoyma with w.gmas Heir tale comgwtioo. 3571.7@A7_tecr*peetions
will doth,work,W dre.V4cnum is nor intanded oroRerd forule(Sce.71%C,Haim.
and Prefssiem Cade:The Contractor's Lianas Lew does tat apply to an owner of - -
Propertywhoholdsorimprove,Nertm.malwho does such wok himself ordarmish 303 — ROUGH MECHANICAL
Its own employes,provided IMI such improvement.nor intended or offered for
We.w employ.the building ofis such improvements
oneysrde or offem,the
awncr-buildmwBl have the buden ofpm.ing that hedid not Wild or improve Na pm- 304 — ROUGH ELECTRICAL
p°"°fwne 505 — FINAL ELECTRICAL
I,uwne
or of Ute property..exclusively contracting with licensed contractors to
construe,the project(Sec.7(.se,Business and profession core:)rte Contractor.u. 508 — FINAL MECHANICAL z� n
cense law does tat apply te an mmar of property who builds or impr,vm marem,anal �(
who commas formch projects with aconsumers)licensed pursuant to the Continuous /`
Llcenu Lew. J /f-
❑1.exempt under Sec. .BKPG fm Ni.reason 7 /
Owner N Date "�
WORKER'S COMPENSATION DECLARATION
1 hereby alarm under penehy of perjury taro of the following decl.dom:
7lhave and will meivuinaCeniOcata ofCornmOo self-in.urt for Wokers Cooper.
tion,as provided for by Section 3700 of the labor Code,for the performance of the
y Section
'�k for which thisgrmit is iamd.
have and
will hoolain
K"of Ne Labor Cude,for the pekrormCanm�rNe wok for which this°ood permit is issued.
MY woke/Cy6�Itd1 rFE erns O Poli0M WORKERS'�.S'
Camerll//�/('�/iAsur Policy No i�ad !
CERIQ'ICATE OF EXEMPDON FROM WORKERS'
- COMPENSATION INSURANCE
(This sari.oxidant becomptned ifOrc From,is forum hundred&H.($100)
or Ina) /
I certify wt in the peifomunce nits.work for which this permit is iamd,I shall
not employrson in any manner ,�a_m Scomy}uhiect to the Wolcott.Co.,.. /s
Anion laws of lifomia.Date r a!!JJ /`—/
Applicant ,
NOTICE TO PLICANT: f,atter�irWthis Certificate of exemption,you should -
becomes oy it Wokcro Coons or nun provisions of the Labor Cade,you nun
forthwith comply with such provisions m this permiuhell be deemed invoked.
CONSTRUCTION LENDING AGENCY
Q 0 I hereby elExm that Neu is a construction lending agency for the performance of
the work for which this perm03
it Is issued(Sec.37.Civ.C.)
-
lenders Name
C4 > Lauder.Address .
W Q 1 certify nut I have reel Bus application and sum Nat the above information is
a Co.,.I agree to comply with 91 city and county odimnces and state laws refining to
V 0 buildineonuo
cstrucn,and hereby smlmdec repreunutivea of this city,.emotipon the
above-mentioned property for inspection purposes.
Lr. f✓ (we)sins in use.indemnify end kap hamtlet the city of cupenino.geirnt
C.) linbilttis,jdgments,conaand capenea which may in my way accme ysimt mid City
�r W in conu9ucme of Neemming of dun permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
V W) SOURCBREGUTATIONS.
/w-• l��^+& V Led
`• 15ignuurt of AppliceHAZAnct tae �..►/f O�
HAZARDOUS MATERIALS DISCLOSURE
Willy 11a culam o mmucipal core.cupms g.12.auntie luArdoand Salary Re-roofs
u deflrd by the Cupertino Municipal Code.Chapter 9.12,and the HedN erd S.fsy
Code, 0hon iss3xa)7 Type of Roof
❑Yes �No
Will the anthems. wrt building occupant use equipment or devices which All roofs shall be inspected prior to an yy roofing material being
cmithatadaus aU commitments a defined by Ne Bay Area Ah Quality Mamgamcnt installed. If a roof is installed without first obtaining an inspection
n"" I a ree to remove all new materials for inspection. Applicant
❑Yes g
Ihave rad Ne hassidoa�mlm;av,egaimmnlr adder Chapter 6,95 of the Cali- understands and will comply with all non point source regulations.
fwnia HAIN&safety code,Seeman,25505,25533 and 2553a.1 understand that if the
building does not currently haves tenant,that it is my responsibilitym notify Ne occupant
of Nc n�yinmmu whit n be melprior m iumnce of a Cenilicue of Oc tape y.
uthim,/ Signature of Applicant Date
Owmt m amhonzeA agent s
All roof coverings to be Class"B"or better
OFFICE