00020190 CITY OF CUPERTINO ,+ ` PE"ITNO. .1
BUILDING tavtsrov PERMIT COI TRAC LxQ�R II EORMi11I Nit , 0 p Ole?
BUILDING ADDRESS: ••1� Vp9L_N Q � , `�� SANITARY NO. - APPLICATION SUBMMAL DATE
D STIED b l -� k'4t C'-V1CL�(4J�`1��
NIC,
CONfAOLM
PID 4 •r (t�
8 D- SUM /&CD
ARCHITMTMNGi14rER BULGING PERMIT INF ty .
3 0 0V�EAM1 Y-B L� �1
J's,F
Z O y LICENSED CONTRACTOR'S DECLARATION
O Z_1 1 hesaby aRam that I aes licehud under provisions of Chapter 9(cammchhrio9 Job Description
r 4 t= wish Section7")of Division 3 of tte Betimes and Rofession+Code,aud my license is
in hull fora and io11
p License Clea q R Lic.N
Cmuaur
�—AAAjtCHI'IELTS DECLA ATION ;
� y I undrnund my gland andl w used ss public recatds
o Lbcared Fmfneboml
uaSM OWNER-BUE.DER DECLARATION
E=Z< 1 hereby aRrm that i vet Hemp,from we Conuaufv License Law for the
Z O lalbaving...(Section 7031.5,Business and Pmfuaiona Code:Any city or aunty
e 3$ which taryira a penoit as construct,saw.bmpmve,dermliN,or repair any structure Sq. Ft. Floor Area - Valuation
prior to its issuance,9.requires we applicant frostub permit to Ill..sigmdsutement
that the p"wo ou",0,
the Conte t beaus law(Chapter 9 '
(commencing will,Section 7=)ofDivision Sof the Bminas and Professions Code)in APN Number Occupancy Type
oust io is eampt any.,b and W<was res w<ct,,hid ascription.A.is violation or �' r O 3 P Y YP
Section 703 1.5 by any dreg dw t fa a perMuubjecu Ne applicanuo a civil penal of l0
ana mart wen dv prove dollen y empl
Lu owmr ar ode: eny.orinuoW. iceea Law.due,
non v y to
n madown.a Required Inspections
rose daw<wak,.nd wc.trmtnre i.rhe inteodpdoraReand rawa(sec.nus,enaihhe.a �/t\\\1
and Phofenlous Code:The billion.themYv Liceme Law dm nor reply es lf owner of
hpouportyis own who wilds or sided Usuch fi and who don such work himself or t cal for '
his own amplay, s Willi nd wu such Impro."it w are nor intended m offered for
sale.ILhowaanta wildingoriinpuamasiv at h did nomild or
impact
she
onus,of ldtt will have we burden of proving wort w did not build or improve fm pur-
pose al Won).
ci 1,u ownn of 0te progeny,,Business eadus and emtatng with licensed Constantine.
U.comtuu we Project(Sec.]tu,w.of
and Ruwho Wi d.co Tw Comocto t, nd
cane Law dors set apply to ur owmr of progeny who wilds or improves wdera,and
who emtxts for such pmj«u with econtracta(a)licensed pursuant to tw Contacmis +
Liana law.
Iunnemparde'Sec. ,BAPCforwist<uon '
Gwmr Dotets
�t WORKER'S COMPENSATION DECLARATION
1 1 herebyandwarsonunh pnWty of ofConsotoortrcfdlowingWorkeauma:
❑Ihave andwillt for by etion 3700 ofCeLaborion(to ode.art forWorker's Comp the
atlon.u provided for by Section 3]00 of rte laws Code,fa the petfomurce of the
work for which this paira is issued.
❑I has and will m e,for Wotkcls Consternationshe work,
for hi h rtquisnd by Section
3700 of we labor Code,for trc((a��rfwm�eArcp�e of the woh foyr�wlhiHchat<w,iv..pe�rm/it�is ia1uM_. '�p
CWo el a t coats 11g.7.��randyNlley
CERTIFICATE OF EKEMPi*ION FROM WORKERS' -•�h
COMPENSATION INSURANCE ,'
(This renins medna awe be mPleted ifPerseids froom hundrM"Im($100) / I'- ISS(.i�1h p+ri"�
or kat
I,any watbn we an,romam<nf NewaHmwhbje
set employ any person in any menntt w n m wahm subject w we wartan'Comas-
cation Lewy of California.Data reSGrs,'r
Applicant '
NO'oCE TO APPLICANT:If,i fte,making this Certificate of Exemption.you should URII p`(j,1. i I . a':'••h",: l i�� ` -
become subject to the Wo s Compensation ptovisiom of we Labor Code,you mon y t•hb., _
foMwiw comply with etch ptovbsions or*is penniuhall w domed mvaked. Cornpl ,;,p.' 3; I• '-�L.•.
z CONMUCTIONLENDINGAGENCY Permit >✓c;,;; t-i (.ail UI, f �cf$
O O I hereby fund wet were is a construction lauding agency for we an9emaaee of -
rte work for which this permit is issued(Sec.309].Civ.C.)
[�7�•' Lawkes Name
a j Leader's Address .From-----
F4 1
rom— — --
Q1 unity duty
i i have read this application and se that the above bnfomution is - -
0+ area,.l agree to imply wiw ell city east county aNimneev and auto laws relating to n r, _
O Z building comwction,and hereby autbohire aepresentativer of this city to enter upon w< Signature
U O above-memianud ProOenY far inapatlou puryorn.
fs (We)agne to tea,indemnify and keep harmless the City of Cup<nino.gout - -
O CF.7 liabilities judgmeme costs and expenses which may in any way accrue against said City D�`^:
y. W in cmsequsec<of wegrensingbr Otis ptmth. to
�+ 0.0. APPLICANT UNDERSTANDS AND WILL COMPLY WITII ALL NON-POINT
U SOURCE REGULATIONS.
S,rol ure or APPlieanVConttata Data n �� ���/ /'d��✓�
HAZARDOUS MATERIALS DISCLOSURE (h Will the,thitherto or future Wilding occupant store or handle hiatandwis onabonal Re-roofs '
as&fluid by tw Cupertino Municipal Code,Chapter 9.12,and to Huth wand Safety .
Cade,Sector 25532(aC Type of Roof
❑Y<s 040 -
Wilithe applicant orfuture wilding occupant use equipment ordevicas which All roofs shall be inspected prior to any roofing material being
emit hauNoue aircontamiuents in desnnd by tw Bey Asa Ab Quality Mamganent installed. If a roof,is Installed without first obtaining an inspection
I a ree to remove all new materials for inspection. Applicant
❑Yea o.
Ihave read the hawdoue secunda rtquimmrnu under Chapter 6.95 of tic Cali-
understands and will comply with all non point source regulations.
romu Health At Safety Code.Sections,25505.35333 and 2553 L I uMenuvtl wet if we '
building dors nor entrain It tenanLwmbt is my myon' ilitymnaify we occupant
of tw aequhmrnnw t �AI¢ ueoce Cctilis.aOtt
�\�tea D^
Data Signature of Applicant Date
em
Data
All roof coverings to be Class"B"or better
OFFICE