00050135 CITY OF CUPERTINO PERMrr NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: O��or
BUILOINOADD'R1PSS: F G
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SANITARY NO, APPL TION
gUBMITTALDATE
OWNER'S NAME.: 4�/h 1 C491, I � `�I
O S/v/ /V NIC /%' CONTROL a
•) ARCHITECT/ENGINEER MIT INFO
Sf
2 p y i LICENSED CONTRACTOR'S DECLARATION
0�=' Ihereby air=Na l an licensed under provisions of Chapter 9(commrncing Job Description
<F Hl_u9 wiNSccrion and
sion3af toBusimaaud Rofmdom Cale.andmylittnse is
y Y f J in NII force and eEUt. /1 y C
00 i License Clot Lic.M `"' G8A}` (�Lwse� /A w
Date Conaacmr r l
L u�O 6 ARCHITECTS DECLARATION TO Per C�IJ�/U/� /�fy/' �2 �•(f
m�a—I I undertund my plam shall baMata u public rmmds
iG O licensed Professional
OWNER-BULLDER DECLARATION
(= G 1 hereby affmn that I am exempt from the Commetor's License law for the
a ❑ following.awes.(Section 7031.3,Business and Pmfnsium Cure:My city or county
K
$ which requires a permit to construct.dor,Improve,demolish,or repair any summa, S FL Floor Area Valuation
pdmmiuiuuams,danrequires the applicant for swhpem's Licauuse Tatw(Cacmem q'
Nat ha.i.gmdpSr o.ent t000)of provisions eBusio dProfli=Cogm9
(co,he is exempth Secdon]000)of bass for ra alleged
exemption.
yvi Cade)of APN Number Occupancy Type
That io is exempt Nvdfrom and to breis fan Ne ellcgdd oxempnt I.My it halt,
of
Section]031.3 by tiny applicant for,a permit anbjmm Ne epplicanuo a civil penalty of
rot mon en vhundred dollars ;71—
, 3 � 00
/
❑
Required Inspections
wEldo Nework.wM soumureistrotimerdedmoffv fm We(Sm.7W,Bwiwss
and Professions Code:The Cantmcmis Liams law does not apply to an awrcr of /)
property who builds or imp o.therms,and who does such work himself or though �,'7
his own emplomoven ria proddetl r i such improvements Is sol wart no intended r offered fan ��•
hale.If,w howewt Us,building or improvement Is sold nese yesnde in olffered the
ownqq-builder will have Ne burden of ptovin[Nat Ire did not build or improve fm pm-
FFVV,,.•{{, we awasr of Ne property am exclusively connotations wit licensed conbmpm to
examwm todomoan,appl(Saoy
]redowner of andny whsions Cnde:)The Conuarms.,Li-
cense caw dww ret apply m ts owner of property who sed p or imwo Ma Cordon,end
License contracts for such projects with econtnemr(q licensed purtuanuo the Cantnetora
License Law.
❑lam exemP dor sec. ,Bkm Nis moon
Owner O Dao PCf/l6/VxP ,w
ilia
WORKER'S COMPENSATION DECLARATION \ '
affirm Much,penally afNrjuryowoftefoliowingd imiiom:
Horsetailn.of willfor by ttion 37M of Cwwrnsto Coif-insurefooWphelacefro-
sawn,u which this
for by Station 3]00 of the Labor Code,for the perfomuntt mf the
wok fan which Nis pmW,is issued.
❑1 have end will od,maintain,Workots Compensation Iwmawhi h his erm by Salm^
My of the Labor Code,fur thewnencameof the work forwhichNis pcnnit is innuod.
Ca ter.Worker's Compensation Inhuronw cemim and Polity number me'.
Carried Policy No,
CEdITIFICAM OF COMPENSATION
I N MOM WORKERS'
COCOMPENSATIONNSURANCE '
(Thea woman nand am be completed ifthe permit is froom hundred dollert(g IOD) ,
or less.) ` I
I certify that in the perfmrwwe of the work for which this permit is itium,I shall
not cmpwy any ponos in any manner m as to become subjecuo the Worker'Compen-
section laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certifies.of Exemption,Y.should
become subject o the Worte(s compensation previsions of Ne Labor Cade,you must
forthwith comply wit such provisions or this permit shell be deemed rooked,
CONSTRUCTION LENDING AGENCY
0 I hereby affrm Na Noe is a construction lending agency for the performantt of
Z h de,work for which thio Fmtit is issued(Sm.3097.Co.C.)
E.. lenders Name
�i I-andee.Andrew,
W AI xinify Nat I have read this application cad..in tat the o neve informed.is
= Z Correct.l agree to comply with di city and county o wmtts and au¢laws re6tin8 m
U 0 building comtruction,and hereby ormisire mprnenutivo mtiwcity.liner upon to
above-mentimmi prowny ire impation purfamo.
Lr+ Ew
We)agree to Mve,indemnify end kap bermins the City of Cupertino against
C t.) liabilities,judgmemm ensu and expenses which may in any way accrue ammo mid City
W is con.sequcwe of the granting of this permit
[y alp APPLICANT UNDERSTANDS AND W111,COMPLY WITH AI.L NON-POINT
C~.7 SOURCE.RF.GULA3'IONS.
Signature of ApplicandConoactw Data
HAZARDOUS MATERIALS DISCLOSURE
Will Neappticant to future building mcupant time or hadle haperdous matend Re-roofs
as defined by the Cupertino Municipal Conn.Chapter 9.12.and the Health and Safety
Code.SectionM32(da Type of Roof
❑Yes ❑No
Will the applicant or future Wilding memoirs use equipment wdevics,which All roofs shall be inspected prior to anyy roofing material being
most hamrdmus ai,iMmarntunu a defined by the Bey Area Air Quality Management installed. If a roof is Installed without first obtaining an inspection
°i"""' I agree to remove all new materials for inspection. Applicant
❑Yes ONO d
I"In read to laadw,materials regaimmmt,manor Chapter 6,95 of the Gall- un erstands and will comply with all non point source regulations.
(oma Health
R Safety dly ha Sermons 23hat i 23333 aid 2333e.I understand!tat if to �//�/09
building does rid Safety adle.S clow, that it is my responsibility 1 mnmBy themcupant /i '/V/ r
of the"M u which must be met prior misnmoe of a Certificate of ry. 7T
✓� Signature of Applicant Date
Ownttor auNori a8mt Dare
All roof coverings to be Class"B"or better
OFFICE