00050010 CITY OF CUPERTINO PERMTTNO,
BUILDING DIVISION PERMIT CONT/(IRA:CTTOOR/JI/NF0
'pfll'/'/1fR�,M�A�T�I/ON: IO
BUILDING ADDRESS: /�AC.�—� ✓� - `+"V�l/ar� SANITARY NOAPPLIC
. ATION SUBMITTAL DAT
�k09 u `
O\LNER'SNAME /
�Ae NI❑C CONTROI,p
ON_: a'Y V
40
ARCHITEC YIENGINEER ./Dy_ /� �,`` HOLDING PERFIUINFO
aU�
F: v LICENSED CONTRACTOR'S DECLARATION
e I hereby affirm met I em licensed under Provisions of Chapter 9(commenting Job Description
p2—O
F r,r J wish S«rmande)of Divisi«3ofine Busi«umtl Rvfeesiou Code,WmY littna ie
in full force and effect.
ro0 d Limits:Class Lica#
m 3
t a 0< ARCHITECT'S DECLARATION
y y� I endenuuN mY Plw aIW I be used as public rmords DI
w'c z LiOnad Pofcssiona
v3 y
OWNER-BUR-DER DECLARATION
C Z a I hereby affirm that 1 sic exempt from the Contractors License Lew for the
wF C following fusion.(Section 7031.5,Busi«ss cad Professions Cuda:Any city or county
3 m which m rims a permit to construct,edter,improve,douncha t,or apeir any Worctom Sq. Ft. Floor Area /� Vallla ion
pct«a ax mum«e.Jas mi,ima the applicant for each pemut to file a ug«d autmesm
Out he is licensed piuumuo Ne provisions of the Comtactora License Law(Chapter 9
(sOmmeneOgivim Sectian 7")Of Division Soli ma Business and Predfassu na cme)m PN {, O
mat he is exempt thertm fmand the basis for due alleged exemption.Any violation of YET' ccu Pane Y Type
Section]031.5 by any applicant for a Perrot&objects the applicant to a civil penalty of 2 s I
pt mom dun five hundred dollars/5500).
LasawnerarmePrnPertr.armrempmr«.withwage.atheirsoleeampemradon, Required Inspections
will dons"ick,sadt: .e aCumis«timctdcd La�erteforsaefplyo Moues
and arty wim CMB:The Conmcwn.License law does n«apply himself lf owner of
property who builds or vidrovu thcaon,ad who eau ream work dedOro through
his own however
the provided Nat such improvements sold w x nn intended«ol5etad f«
We.IL however,drc Wilding or en of
is sold within ane Wild
in m mai Forp he
r.
pwntnbuilan will have the Wtden of proving that W die not Wild«improve f«par.
potentiate.).
C]h as edea,or ct Sm.704 an exclusivelyssad contracting with licensed canuanm to
Ouse a desue ma apply
Burrowed Py who Wilds
Cede)The Cs hareco.Ld
cause law sou not chilly u m owner ommuctony who Wilds m tion W the theaemn,and
who commas for such pmjeca Witco a conmctor(.)licensed puraum to the Conuectds
Lim'".. law.
pl am ucmpt unser Sec. .B @ P C f«this mason
Qwnt DataS
WORKER'S COMPENSATION DECLARATION /
1hareby nodwalumundo Penalty of perjury Cuomo,1.
tffost.or Wolon'.Cu:
va lheve arovidelfll or by a tion 37 0of the ala al6inwref«Workers Comp the
sari«, r pmvidM for mi Section 3100 of the Lahr Cak.for the pertomun«or the
work av whish this permit is issued. O
❑I love ens will
Wnrbdr Compensation suunte,u uby Sutton
3]00x(the labor Cock,for ed pcRomofthe works f«which this Permit O
is jawed.
Mywmk!c Comgp dont shi =Policy r
Carrier:7'sA f7C s N 65MItIn,No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section«etl nor W completed i(me permit is for.)«huearW dollen(SIM)
or less.)
I certify asst in me,'dortnawe of the w«k f«which mix pemat is iuued.I,hall
not employ any"on in my On t W me mbj«t m me Wortrri Compen-
..ionlaelifomu.Dta (1
Alwlicmt YOi V1 -
NOTICE PLIC NT: L u making this Cmifcaa of ExemPuon,you should
become au ij t to me Workers Compensation provisions of the labor Code.You must
forthwith comply with such Provisions or this Permit shell be deemed evoked.
CONSTRUCTION LENDING AGENCY
O O TMabyahthi the thea isruml(Sm,30 lc Ming agency f«me perfmmwce of
Z the wick for which this Permit is issued IS«.l09],Civ.CJ
Leader.Name
g'(r > Landers Adaasa _
Wa I certify met 1 leve read this ep,)ic.1i.o..it sea met the aMve information A
96 mmact.I agree to comply with JI city ad coumy cr limi and ale laws relating to
,7. Z building mrisuucuon,and hereby amhonaeapreanutive,rdmis city to ente,imm the
U O above mentioned pmpeny for inspection jumpnua.
Vo F (We)agree to ave,indemnify and tarp harmleas the City of Cupertino against
O t.7 liabilities,judgment..mus aM a.pm.which may In any way e«me.gti at said City
n consequence of dic
of his
t.
CW to PPLICANT ONIDRSTAN US AND WI 1..1,COMPLY WIT[I ALL NOOWN-1RJll///y�]T�\
V 1DDN{aTNE .A'rl<IN 13�•
/�- Si ]/ocOff ApliccaantlContnctor
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicmt«fo..Wilding«cupim nom«hmNe hazadoua maenal Re-roofs
on defined by the Cupenino Manic' al Cede,Chapter 9.12,rid the Hours and Safety
Code,Section 2553x.)] Type of Roof
❑Yes
Will me ePPlWant ter future Wilding use equipment or devices which All roofs shall be inspected prior to any roofing material being
am haardnaa.iIconuminmu'.`gefinedbytheBayAxeAirQuaityMmegement installed. If a roof is installed without first obtaining an inspection
""`] I
❑Yu agree to remove all new materials for inspection. Applicant
Ile mad me hazardous material.rcquimmmu,mide,Chapter 695 of the Cali. un erstands-and will comply with all non point source regulations.
fomite Health A Safay Code.S«daa 25505,25535 and 2553x.1 understand that if the
building does n«cumemlym aanenI that it is my axpomibiliry i unity dammpmt
f It it ,tar Mpg. I be met .'isaime9cf.a Cenitime of Occupancy,
( � i1.t.,irL' iGi�� " Signature of Applicant Date
Ow ormationsed agent Data
v All roof coverings to be Class"B"or better
OFFICE