00120146 CITY OF CUPERTINO - -
BUILDING DIVISION PERMIT' CONTRACTOR INFORMATION:
nuu.DINCADDRepr):L Ird._ (2IVf11RE X =TRT11,40 1A.LIMIING 001 eFTG0
OWNERS NAME' fNqu-'r- rrn"OS30lq102Yl S-DE (4TZA FLV _JJ
SURDATE2pgAM
PHONE: (4W 28,3—,0,rj 8 SANITARY NO. CONTROL NO.
0,-,Z ARCH]rECTENGINEER: .. BUILDING PERMIT INr
w C BLDG ELECT LU MECH
'LICENSED CONTRACTOR'S DECLARATION
Z y'� 1 hereb IRnn lint 1 inn Ileenscd under lob Descrl tion
r)z_ ( a ped Pafeof Chanter 9 d.,lice'ng P
P5C wish Scei ot]rp0lar D'vsnn ioftho dus,nseunJ Pndesvi my Cnde.,d myl cense r
f Id in run r ea an ur Fill=If�7::1WRTF�R Mf-lIN/ WATI�i I-ff;'F�iTFSi
1. lass l Jp Lc „ -1, 0 .
3 ed �Z--�'l—io0 Cadeactnr_GrfJllGh eta
ARCH]I'ECT'S DECLARATIO P/,yyth�
g _ I understand my plans shall be used as public oboN. '
w 5 p O Licensed Pmficant t a] -
OW NIHI-BUILDER DECLARATION
I hereby aBina that Ian,exempt from in,Contractor's Licescue Law for the .. .
following wasun.(Section 7011.5,Business and Professions Coda.Any aly or county - I . •-
S S 0 whim requites a permit to cnnsunci,later,improve,demolish,or repair any drucmre
prinatc,iiIit)requires thppli e ar,achp into fifen,agreed,adenneand
that he is licensednnatioutt m provisions of the C I'a ficione L (Ci.,,,,9 S Ft. Floor Area - < k- Valuation -
(co t n�ngwithSeeion]Bal)ofDavis n3 of the Badness dProfessions Code) q• .G.d!10Q '
or that he is exanpt therefrom and the basis fin the alleged exemption.Anviolation ' -of Siouan 7031.5 by any applicant fo.pandat subjects the applicant to a avis penalty
of nm mare data five hundred dollars(ssnn). i7 �l� uMer Occupancy Type
❑1.as awnan,f the p,opi or my cnnplevees with wages as their sole eonponsation,
will do the work,and the structure is not intended nr offered for xnle fSce.7044,
Business,ad Profession,Code The Conlraatof,License Law does not apply he.n ctP1Ft .... I jplpFT'tf7 GGFiR�Q�J Il eetions
.wid,of Property Who builds or imprnvev thereon,vad who does such work himself
h ...gh his owa enrployeas.pooided that Intel,in,prooms are a,,,intended of 301 .-. R0113I'4 R,UI,011 3
offered for sale.IC however,the building or improvement is sold within one year of
completion the owner-huildcr will have the harden of proving that he did nal build or 5@2 — F:.INPO.- G'L.UM191b i EbER'GY
improve for purpose of s.It,):
- e
El 1.as r of the'Innerly,no exclusively d n nichng with licensed contract in, ..07 F.114-1- I"U MBIhIG -constrict the project S 7044 Basin... d Profession,C )The C rbacwr's
Law does ad.1111t act tfl pay whohaik ' .thereon ,
and who curroes ba such pubject,withe t' r(s)licensed 53assean,to the , ..
Contractor's L'couseLa
underEd
See, RkPCfor this reason -
Owner - DNS
WO cyCOMPENSATION Dr:CLARA'I'ION
' I h by Ih .n ,pc al y f'c
❑ I have and 'll neuron. it Ccd,F,,:i,a of Croeiant t,wit-urear, f r Worker's
Comp info,, us pr IDeJ for by Section 3700 of the Labor Code, for the -
proararanceof the work Ibr,hi,h this penult is issued.
❑1 have and will maintain Worker c Conpclna inn Insunnce,as rarylred by Section _
3700 of)pe-Labor Code,far the pefor nance of the work far which this permit is
y Worker's C mpensatmn Inxumnce carrier t sl Policy numlmr aa: t
CLRTIIICATI(lN OP F,XEMP]ION PROM WORKERS' ,
COMPENSATION INSURANCE - -
(This section neN not be mmplded If the permit is for one hundred dullard - -
($1001 or less.l
I.edify that in the'erforn arbe of the wnrk for which this permit is Issued,1
shall nal mnploy+my Person in any ouninei su it,to bonne subject to Ne Workers'
Conpcnxadno Lows of California.Data _
Applicant -
NOTICE TO APPLICANT.IL after In dong this Cenipcme of P.xeoption,you should t
become sub)ect to the Worker's Compensation provisions of the 1-awr Code,you nuol
Q Q forthwith emnply with such prnvlsinas or this peril salll he deeneed invoked.
z
CONthemis constrION iction
LENDING AGENCY
a ? i thereby wit ich that proton
ss csued(Sc. Iend'mgagency for Inc Iurromtunce
W of the wok fnr which this'snub is issued(Sec.3097,Civ.G -
Gu A Lender's Nude -
U z Leader's Address
U Q I certify that l have rend this npplicusnand state Incline above bilateral lonis _
LTi [r es rrect.I accord'.comply with all city and county n hand..and dote laws relining
CC.7 to building construction,and herchytnmaize reprcmnmtives of this city te enter open
L� the crowd-mentioned properly for inspection punpnses.
.Fa Iy (Wc)agmcrosavc,indcnnifytind kcepharn,Iessthe Chy of Cupertino u,diam
V1 liabilities,Judgments,costs and expenses which'n,4Y in any way ave a against said
U- C t ucq •neo of y,e running of this permit
SOUR AV "411 A 5 pDWILLCOMPL,WITHALLNONJPOINT Y: Datef�
R lI- I2-27—Ur� Issue
Signeoreo(Appncaweantraetnr Dme Vc)fslsh,
IIABARDOUS MATERIALS DISCLOSURE _
Will tine applicant or future budding occupant store or handle hazardous anterialrs defined by the Copeninn Municipal Cale,Chapter 9.12,tend the Health and Safety
Code.Section 25532(.)'? -
w" °No inspected prior to any roofing material being installed.
will the applicant or rutn'cbudding occupant use equipmant Is devices whiched without first obtaining an inspection, I agree to remove
coil huzandon,f,,aturaire is as defined by We Bay Area Air Quality Man.gement
Di.tricO all new materials for inspection. Applicant understands and will comply with
ores ❑No all non-point source regulations.
1 have read the Safety
Coon omen,2 oyuireocnw under, 4.1 can esta of the
C.1-famio an,
&Salary Cada,Sections25505,25533 and 25534.1 undersand?hut
e dlaing does not cvtrently have n tunant,that,,is my respamiHaity to caddy the '
.. l rey ire cuts w h hunt M met Prior m issuance of CertlOam of
ucc
oee a� Signature of Applicant Date
L Zl -00
owner orandtori,alagent - Dale All roof coverings to be Class "B" or better
OFFICE is