00050147 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: c)(00 Q tf
BUILDING ADDRESS: I 0./ n / -)' r! • SANITARYNO. APSIJBM�AT
OWN ..NAMV Id a v J9F C.�'
a V SIC CONTROLp
Z li 8 2-are 33 BULUINGI'ERMI'TINFO
RCHITF. :NGINEER '
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Io O y LICENSED CONTRACTOR'S DECLARATION
OZ=O I hereby aHinm that 1 un(teemed.Mer Provisions of Chapter 9(commencing _ //n Ob SC( lion
F 6.1
su wish Section 7(100)ofDivision 3 ofrhe Busin«samd Prefeasiom Csdr.and my license is T/o �' 0l ga—f �
F� in full Twee end ew 1 5 , RC/" 9
Q o< ficvue Cl AR Lie.. X04 G•.ua,...�2.. S-�u-P '—�•�,
3�H Datc Conteseur
t u.O; ARCHITECTS DECLARA N
1 unth nand my plans shall W used as public records
uGtai sLieerued ProfesslmW /jam��J
c sets=y OWNER-BUILDER DECLARATION rr
1 hereby afnn Ih l I am esemp from Ne Contract&,Licc..Law for the
z: following reason.(Section 703 1.5,Buaimas aM Profeni«e Code:Any city Or county
which requires a permit m construct.alar.improve,demolish.«repair any svuery e
prim tons issuance,esorcqune,theapplicamfe".thpermiuufile.Miffed statement Sq�FLp—Floor Area Valuation
Pont
that he is limned pursuant t.the provisions of the Connacsala License law(Chagn 9 /-p O /5, 760 y V
(commencing with Section 7")of Dlvlsion3 of the Business and PmfCsslorn COM)of APN Number Occupancy
that he is e..,,d ercfram and the basis for the allOW C.empion Any violane ation of I _ O p y Type
Section 7031.5 by any applicant fora perom subjetla she applicant ...ivil pemlry.f 0
rot more thas five hundred dollen(5500).
❑Lasowneror Ne popeny.or my employees with wages as their sole compevuion, Required Inspections
will dothewmk,endo: nmcureisna.Livens mowned forala(Sec.0094.Biour,a
sed property
who
Code:The C.nrxmer'a License law dors not apply to an or
or
property who builds or improves thenen,pr who does such work himself or ewueh
his CO.employes,Wild., Nat such improvements thin not intended m offcrW for
snareH,howcvu.thr Wild., within oneyethof completion,the
nWBam will met da Widen or).wdne that he ata.o Wild in improv for pur-
pose
..i.e.ethe :aTAA a a� � 1$00�
1,u owner of 0n property,am exclusively conc.ung with licensed contractors to `e v\tr'�1,4`+1
wnswct the projtat(Sta.)090.Business aM Pmfestions Code:)T1u Conv.mora V-
Cenre law does not apply m an owner of property wW builds or improves thereon.and wWc.Lams f.r sucM1 proltas,widrecontrxmr(s)IicenaN pursuant to tW Canvectnls
Lanni law.
❑Lem czcmPt urMu Sm. .BkPCf«this rrasan /
Owner Date
WORKER'S COMPENSATION DECLARATION
I hareby affirm under penaRy of perjury one of the following declantiom:
IMveeMwillmaMWnaCenitateofConunuoulLinsumfwWmkchCbmpen-
Orion.as provided for by Section 3700 of du Labor Catlin.for Me pedotmann of tet
aaawwwpppzzzk fm which this permit h issued.
7(]I have and will maintain Worleces Compensation Insurance,as required by Section
"By t th'��e�'l"ay'WJ/n�r C�ode�,fes the pcatR�gom�ume of rhe work fesgpuli�ichgnWis p s�W1�f
Carrier Cgynp�vatiw�loura—aClarti«Put-No.YC�O
CERTIFICATE OF EXEMPTION FROM WORKERS' l Z t I
COMPENSATION INSURANCE
or leas.)(This sermon need no W completed tithe permit is for..hundred Mi.(S100)
MAY 1 9 2000
I employ
any Bus in the myfrmmae of Ne work for which this o Me,permitis issued L shall
not employ any person in any manner w u m Wc.me mbjtat N the Workers Compen-
pi Laws of California.Da¢
Applicant
NOTICE TO APPLICANT:If,Co making this Cartiicau M Lidam on,yes u m•Ist By
become h Comply
y it Worker Compensation Mi, provisions of rhe Labor Cade.you must
forthwith comply with such Provisions or thi:permit WII W d«mW rcvokW.
ruCONSTRUCTION LENDING AGENCY
Q I hereby am thin then isaconwaetim,lending agency for the prff..e of
Me,w
Z thmk for which this permil is I soW(Sae 3097,Civ.C.)
lender,Name
�a , tender's Address
I..fy thin 1 have rtaa this application and vase that Ne above information is
96acct.I agree b e to comply with all city and county ordinances astate laws naming an.7 Z Wildin,,mmuucoon.and Wrebyam orne,rcpese.Wivea ofMis city to coot upon Ne
f.J ebovs.mentioned popsy for inspection purposes
fa. F' (Ws).erre tu ave.indemnify sm knP bamtlas Ne City of Cupertino agairot
0 V liabilities,judgments,tests and Cape..,which may in any way accmC.,amst aid City
�. W in consequence of the granting of this permit.
f'w 6. APPLICANT UNIIERtirANDSANU WILL COMPLY wi of ALL NON POINT'
feel Z SOURCP '
�—�- S/K/oo CvP.�S S3 �'
Sigwuc or Applic Convactm dam
ALkRDOUS MATERIALS DISCLOSURE
Will ytheCpentor Nun Wiling mcupatr 9.12.am
Heallousmmmal Re-roofs
u defined io the Cupertino Municipal Code.Chapter 9.11,end the Health and Safety Type of Roof
Cpee,Section sss3x.n / yp
[3Yu
Win the applicant or future Wilding mcupthn use equipment or devices which All roofs shall be inspected prior to any roofing material being,
emit haard.us air conuminanu as o define by the Bay Arca Air Quality Managerecnt installed. If a roof is installed without first obtaining an inspection
Distr1ct? - I a ree to remove all new materials for inspection. Applicant
]Yss
I have read the hnzardoua nada(,rcquiremcnu under Chapter 6.95 of the Cali- un erstands will comply with all non point source regulations.
rmMa Halth&Safety Code,Stations 25505.25533 and 2553x.I understand that if the s // /O
Fuildingdma z c u hate Nm' is my mpondbiliry to nod pant L/ L/
of the requi cs which ,I W me pi nuance of a Creme �9�w/ry
/7 /LU Signature of App Icanl Date
Owner m euthonzcd age ��
All roof coverings to be Class"B"or better
OFFICE