04120035 CIT`_.,OF CUPERTINO
BUILDING DIVISION PERIW CONTRACTOR-INFOR ON -
..-,_,. �
BUILDING ADDRESS: SHEPARD' S CONSTRUCTION PERM IT NO04120035
77 LILY AV
4PNEWS NAME: PERMIT LSUE DATE
CRAIG SILVER 879 AZALEA DR. 12/06/2004
PHONE: SANITARY NO. CONTROL NO.
(408) 377-8045
ARCH1=11INGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
=oo LICENSED CONTRACI'00.'S LARATION
E I any arum mat 1 am uanaed utians of chapter 9 feommeneins Job Description
with oefporoiviaion3orthe Btdm.uoand mfcssianm Cmda.and my license is
imm�f aro ff y REVISION--IN HOUSE USE ONLY
p i Licc CI s "�Lic.p
_�, Dat ` '/ can a O W PERMIT ISSEUD/ ORIG. #04110064
ja tt7.nd my plans shall he used as public cards
w
u Licensed Pmfessimid
+05 OWNER-BUILDER DECLARATION ...
1 hemhy affirm mat I am exempt from the Contractor's License Law for the
00
folnwin (S
g reame. ection 7031.5,Business and Professions Code:Any city lir County _
k m� which requires a permit to construct,cher,improve,demolish,er repair any structure
4e " prior to its issuance.also requires the applicant for such permit to rile a signed statement
� <1
that he is licensed pursuant to provision Of provisioOf NC Commmmi Liana Lew(Chapter9 Sq.Ft. Floor Area Valuation
5 x
F C (commencing exempt
droofo p and tof he Division r of the Business edand PrafAny A Cal,)of $0
y�$ that he u exempt Nuefrom and the baso for Inc alleged exemption.Any viola0on of V
Semon 7031.5 by artyapplirautfar a earm,subjects ale,applicantmacivilpenaltyof APN Number Occupancy Type
Out more Nan fixe hundred dollars(1500).
I,uownv of 0e five
Strad m iscmntrudedwithwageuNei,sole campenhamas
win do Newark.Cod the svunuminno0nmrcense Liwdoes orfared sale n.,ply toim Bahamas Required Inspections
and Professions Code:The Contndon,License Lew dam not hims to en owner or q p
Own emywho pro orimproves thereon,and who dwssuch work himselfedthrough his
how employees,er.th provided mm aueh improvementssold within
not ear o comps tion.forthe o e.If. -
Wilder .Nebwthe, Orden of pmensissoldwithinon,year ofimpra lion,the owner.
Wilder will have tnc burden of proving that he did not build Or improve for pmpm¢of
salcJ.
❑I,u Owner of the property am exclusively contracting with liamsed convenors to
consumt Ne project(Sec.7004,Business and Professions Code:)The Conlnctor's Li
who Lew dors not apply loan owner of prapeny who builds or ant as the
th,remn.and \
who contracts for such projects with a convaztor(s)lianud Pursuant m Ise Canuutors
License Law. \
lam exempt antler Sec. .B&PC for this reason l
net
Data
. \ J
WORKER'S COMPENSATION DECLARATION
1 hereby anion under penalty of perjury one of the fallowing decluatimem
71 I have and will maintain a Certifioto ofConunuo self-insure for Wurker'sCompcn-
utimn,as provided fm by Section 3700 of the Lebo,Code,for the performs.of the
work for which Nis permit is issued.
M 1 have and will maintain Worker's Compensation Iuumme.as required by Section
37M of the Labor Code,for the performance of Ne work for hieh this permit is issued. —
My ,kers Compensation Insurance nrri.mend Pol' bet aa:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Cf As if.need nmbeccandeted ifthep mrsh is forms,hundred dollars(SIM)
or bee)
1 certify Nm in the pert rmenec of the wort{for which mice Dicot t a issued,l shall nm
employ any�Jm vnr sn az16 f qme subjecuothe Workers Compensation
al .. .. .. .__ _ _ ..
Laws of fi'
A lica
ICETO APP 1 .1.oft, making Cenifietne of Exemption,you should
come subjcn so.tfic WodcrS Compensatiy provisions of the Labor Code,you..at
forthwith comply with such prnvisirnss or Nis permit shall be decmcd rooked.
z CONSTRUCTION LENDING AGENCY
'C. I hereby Tom Nat Nero iso comtractinn leading agency for the pofformana of /
R:> to work for which this permit is issued(Sec.3097,Co,C.)
lender's Name
az k dens Address
V Q 1 certify that 1 have read this application and sole that the above information is '
W correct.Iagree to comply with all city and coumy ordinances and some laws relating in
�O building eonswcdon,and hereby authorive eprescmativu of his city to enter upon the
r G ahovc-mentioned property for inspersion purposes.
(We)agree to save,indemnify and keep harmless Be City ar Cuportino against
F" (n liabilities,judgments.come and expenses which may in any way accrue against said City
U z APPLI�neNTeof to granting UNOERSTAN of ArND'WILL COMPLY WITH ALL NON-POINT Issued by: Date
RE LAno
a55 ARe-roofs
t gn r fAppbc Dare
HAZAMUS MATERIALS DISCLOSURE Type of Roof
Will the applicant lir future building Occupant store or handle hazardous material
defined by the Cupeninm Municipal Code.Chapter 9.12,and the Health and Safety
ode.Senimn25532hdlAll roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applieam or furore building occupant usemilipment sur devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit nuardaus air contaminants an,dc0ncd by the Bay Area Air Quality Management all new materials for inspection.
Dims,'? A�
❑Yes
I have mad the haraNnus materials requirements under Chapter 6.95 of the Califor-
nia Health&Safe,Code,Sections 25585,25533 and 25534.1 understand mat ifthe building
does not curcnave aseason,that is u my respomibility to nouly Narup
e em of me
ae , ane eeh t tPH.,toismaneearaccmrcateorQaup ,`Y Signature- Signature of Applicant Date
G
aamariye agent Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35903021 . 00
DATE ISSUED. . . . . . . : 12/06/2004
RECEIPT 4 . . . . . . . . . : 27951
REFERENCE ID # . . . : 04120035
SITE ADDRESS . . . . . : 877 LILY AV
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : CRAIG SILVER
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
RECEIVED FROM . . . . : STEPHEN SHEPARD
CONTRACTOR . . . . . . . : STEPHEN SHEPARD LIC # 23820
COMPANY . . . . . . . . . . : SHEPARD' S CONSTRUCTION
ADDRESS . . . . . . . . . . : 879 AZALEA DR.
CITY/STATE/ZIP SUNNYVALE, CA 94086
TELEPHONE . (408) 377-8045
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---- - ----- ------------- ---------- ---------- - - - ---- ---
13MISCELL FLAT RATE 1 . 00 0 . 40 0 . 00 0 . 40 0 . 00
BPLANCKREP HOURS 4 . 00 348 . 56 0 . 00 348 . 56 0 . 00
TOTAL PERMIT 348 . 96 0 . 00 348 . 96 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- -------- - --- ---- - -------------
OTHER 348 . 96 VISA
TOTAL RECEIPT 348 . 96
SCITY OF CUPERTIN0
CUP TYOf O PERMIT APPLICATION FORM _
efI Z ° D
APN # Date:
Building Address: Mailing Address (if different from building address):
\7 G G
Owner'sNama�Cn41G PhoC ft �35`
Contractor,sVV€ � � � License #6 y 7 y 0
Contact; Phone: Cupertino Business License#:
3-7 7 Fax:
Building Permit Info:
Bldg ❑ Elect ❑ P mb ❑ z Mech ❑
Job Description: J�
Residential ❑
Sq.Ft. Floor Area:
Alp
Cost of Project: Occupancy Group:
Type of Construction: Please check this box if the project is a
second-story addition: ❑
Project Size: Standard ❑ Large Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> IOOK to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax —Resi/Mobile BUILDING
BELEC1000 Elec 600V <_ IOOOA ELECTRICAL
BELEC1001 Flee 600V > I OOOA ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
Igor BINVESTIGA Investigation fee BUILDING
,z 7 �S-1
1of3 7 �[ L
ovv� - CITY OF CUPERTINO*
CITY OF PERMIT APPLICATION FORM
CUPERTINO
Quanti Fee ID Fee Description Fee Group
BMISCELL Miscellaneous Fee BUILDING 2
BMITIGATC Comm. Housing Mit. Fee BUILDING
BNUCOMME New Comm Electric ELECTRICAL
BNUCOMMM New Comm Mechanical MECHANICAL
BNUCOMMP New Comm Plumb PLUMBING
BOVERTIME Inspection Overtime BUILDING
BPBACKFLOW Atmospheric Vacuum PLUMBING
BPCESSPOOL Cesspool PLUMBING
BPERMFEE Bldg Permit Fees BUILDING
BPFIXTURE Pb1g Fixture PLUMBING
BPGAS Gas Piping System Fee PLUMBING
BPINTERCEP Ind Waste Interceptor PLUMBING
BPLANCHK Plan Check Fee BUILDING
BPLANCKADD Plan Check Add Multi BUILDING
BPLANCKREP Plan Check Repeat Fee BUILDING
BPREPIPE Re i e Of Fixtures PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BPSEWER Sewers PLUMBING
BPSPRINK Lawn S rinkler/Backflo PLUMBING
BPSTORM Storm/Rain Water PLUMBING
BPTRAP Kitchen Trap PLUMBING
BPVENT Alt of Drain & Vent PLUMBING
BPWATER InstalUAlter Water Pie PLUMBING
BPWHEATER Water Heater/Vent PLUMBING
BPWSVCS Main Water Service PLUMBING
BREINSPECT Reinspection Fee BUILDING
BREMACOVER A/C Unit> 10,000 cfm MECHANICAL
BREMAIRHAN A/C Units <= 10,000 cfm MECHANICAL
BREMAPPLI Appliance Install MECHANICAL
BREMBUSWAY Remodel Busways ELECTRICAL
BREMFIXT _ Lighting Fixtures ELECTRICAL
BREMFURN Relocation of Furnace MECHANICAL
BREMFURNOV Relo Furnace > I OK btu MECHANICAL
BREMHEAT Heater Installation MECHANICAL
BREMINHOOD Installation of Hood MECHANICAL
BREMMISC Misc Apparatus ELECTRICAL
BREMNRAPP Rem Non-Res Appliance ELECTRICAL
BREMPOLE Pole/Platform Fixture ELECTRICAL
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCA Relocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
2 of 3
C@ kITY OF CUPERTINOV
CUP TYOF O PERMIT APPLICATION FORM
Quantity Fee ID Fee Description Fee Group
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Scb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSPECIAL Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Temporary Bldg Permit BUILDING
BTEMPSVCS Ternp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanical sq. foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Change BUILDING
•
3 of 3
,�. d" �a� 4.vuiLL-Y' `�-,31
..i'm� �y 'fir
r1'J3Wai)�P.d�Y {�SYC1`1�L
'S1]
Assessor's Parcel Number:
Name of owner.
Project address. P11111, I'll 1 111111,
Contact person. one.
NOV 10 2304 Fax.
Net square footage of]CITY 0- F CUPERTIN0
r BUION ®EPAMPT Proposed
Square footage:- First floor: Zrirlu �
Second floor:
Garage:
TOTAL: —tea -0 2-,1
Are there at least two 10 foot by 20 foot clear spaces inside the garage? Y N.
Is privacy protection plantingiequired for the project? Y
On what floor(s) is work being done? Sfi PARK ARRESTER REQUIRE® �.
Brief description ofwork. 7CN L - eAce � �
.-,Code editions:2001_CBC (Y-N)2001 CFC (Y- N)2001 CMC (Y- N) 41
2001 CPC (Y-M2001 NEC (Y - N)
jcl.tC,tk6vMov� ef-��c� 3 ! -K ( 2 GLCl�L.q k/�s//C
ffec"ice=17.17D2-- C X0,4-- -
I 'f
Plan Iteriew Process Work Book Page-B-Revised^/28104
L $
� �
� CDV
m r
\ D
C) <
D
ub
0 0
11'-4 3/8" —
O o
a v
N
O
_ ®o O
®0
3'-0"
r
W Cl)cm
0 p m
Zl n 'o
� I
Co C
N
p
m
---- ------ --- - Z
09
o16'-$"
o
Existing
Eo
o
4"x128 -m -
9' 11
r
23'-41/4" ro
1 y 6ft. x3ft.
71 f 1/4"
�
0 Proposed
o'
s APPROVED
TL
11 _5 1/t3" M ACCORDANC WH THE CITY OB
CUPEIMN CO ANI ,RDI
— — - -- --- -- --- — )ATE
— — - -
91GNEU tale 1/8" = 1'
This set of plan ands .rfiealion1jl Q4�/04
oe kept on the jo all times and it is un
lawful to make.any changes or alteradoos
on same without written permission froom
+be bu€".ding 03pt., City of CuperBno.
The dantpittg of this plan and specdiatons
SHALL POT be held to permit or to be ar
ippraeraf of the VWIW of any provwons
+ irw City Oedrmanice or )rate law
Outlet under sink for garbage disposal fk0 U/D tf
Outlet for dishwasher 2 �0 AA,�
®
16' 1/8"
e/ c r tf
-8 1/8"
4' x 3'wind w 4' x 3' windovti
3'-8 1/4"
R R R R ro
s �� PSN v
o p n
Y
O 55
CGFI CGFI v
a
LfOO ~
ROOF
�
}gyp ' x-
/ lrU\ O R R R R
eces d Florescent Main
ighting
;0 4 x 2 BEAM - — -
—9'-4 7/8' – _ Extend existing gas line to stove top
220 volt for wall oven
-.' ....... - -'; V
m
ro r Existing wall
9'-4 3/4'
Modified
- — Scale 3/8" = 1'
' N
Proposed
0
0 o R
N J
N
4" Dryer Vent though Water and drain connection for washer isting Ceiling Joists
outside wall
NUT YY) orc6pv- 11/5/104
fYr
Existing 2 x 6
ceiling Joists
New Wall A Existing Wall New Wall B
e
Existing
Wall
160c-
_x
Y
O Studs
x s strapped to
o, header Proposed
Ncn Changes
x " to
w .o
Existing
°o Q Wall
LL
Nil N
2'-7 314"
2'-6"
Proposed
Wall B
T-1 5/16"
19 13
Y
U
O
X
N L
O)
C
N w
w .a Proposed
`o Wall A
0
LL
m
2'-6 1/16"
z. p��
residential Standard Calculation Load calculation for 877 Lily Ave
„,,,1„k Version 3.66
STEP 1 Article 220-11 and 16 (a) & (b) .
2500 General Lighting load 7,500
8 Small Appliance 12,000 COPY
1 Laundry circuit 1,500
12/6/2004 7:49
Gen.Lgh.,Sm App.& Laun. Load 21,000
3,000 @ 100%= 3,000 volt-amperes
18,000 @ 35% = 6,300 volt-amperes
0 @ 25% = 0 volt-amperes
STEP 2 Article 220-14 & 15 General Lighting Demand Load 9,300 VA
Heat load »»> watts
N#4
4,700 VA
0 VA Greater of Heat @ 100%vs.A/C @ 125% 5,875 VA
0 VA Total A/C Load 5,875
0 VA
STEP 3 Article 220-17 Appliance Demand Load 6,591 VA
0 Wtr Htrs @ 4500VA 0
2 Refrigerator 2,800 Dryer Demand Load 5,000 VA
Freezer 0'
2 Dishwasher2,060 e m Load 8,000 watts
1Disposals 690 C FF V
1 Trash compactor 780 DEC l)6 Zpp*ervice Demand 34,766 VA
1 Microwave 1,630 T /y �1 �r n
❑ Central Vac 0 GI1 'off OF 'rr"PER1INQmand Load 145 Ampere
Mini refrigerator 0 - l a
g al��L�l Di' (93YIC-M
❑ 0 e ral Demand 102 'Ampere
❑ 0
Ironing Center 0 Min.Service Req. 150 Brker
❑ 1/3 hp Jacuzzi Tub 828
❑ select . Sprinkler Pump 0 !Min. Feeder size
❑ select Well Pump 0 Min. Neutral size 2
select 0 Eq. Grding Cond_ 6
select 0 ❑ Copper
Pool Equip. Panel 0 100% Demand
❑, 0 No Demand
❑ 0 No Demand Total Appliance Load 8,788
4 or more demand @ 75% plus 100% demand loads 6,591
- STEP 4 Article 220-18
Electric Clothes Dryers 5,000 VA
STEP 5 Article 220-19
Electric Ranges 11,600 Col A. demand 8,000 watts
Number of appliances 0
Cooktop Col C demand Existing service is 200 Amprere
�❑Check Box for Gas Range Cooktop Col C demand
Oven(s) Col C demand
Oven(s) Col C demand
Number of appliances 0 Dem.Factor 0%
Cooktop& Oven Demand Load 0 watts
Existing
Wall
OFFICE OV
• 4x12
m
c
Y
o Studs
X .0
strapped to
header
o w nom, s^ Fy��err I posed
cto I
¢: •J� C anges
X —
to
LU Existing
`0 DEC 06 2094 Wall
ILL
CjTyov trill
-'PA cN
4x6
supports
2•_6^ �2•_t• i �2'-7 3t4" 4x6 P t attached with metal
bracket
4x6 Post attached with metal
'bracket:::; ,-
aehsed 12rosrn4
!:ip 2•_6.• C ii �� 2•_0•• to'mauae2-
:::Grc1V1 3pc'3Ce sot) concrete support
footings
68 dd1 .f
aJ .
.
y epnpnpm
-110190 _ ,_ ___
IZL Pacinea '
SISIor Joolj 9Xz-£
N
N
W
lT
FSE
• 6
0
s6uijoo-�
M@N
CEIVII
Er .
..s-.z
€C 06 2804
gxq
•
SPARK ARRESTERS:
Cupertino Municipal Code 16.04.060 requires the
installation of a chimney spark arrester, with a
mesh not larger than one-half inch, in all new
construction projects and in all repair or addition
projects which require a building permit and have
a valuation over $1,000.
SMOKE ALARMS:
California Building Code states that when the
valuation of an addition, alteration or repair to a
Group R Occupancy is over $1,000 and a building
permit is required, or when one or more bedrooms
are added or created in an existing Group R
occupancy, smoke alarms must be installed in each
bedroom and in a.centrally located point in the
hallway leading to each bedroom. If the dwelling
unit has more than one story and/or a basement,
smoke alarms must be installed on each story and
in the basement. (Exception: Repairs to the
exterior surfaces of a Group R Occupancy are exempt from
these smoke alarm requirements)
CITY OF CUPERTINO y ^"•- ffix s' F �''% + "' °"°� *'�
BmL mrvc OrvISION PERMIT -. hCONTRA,C.TQR INFORMATION ---- —
auaolNCADDREss: - SHEPARD ' S CONSTRUCTION PMMITNO04120035
877 LILY AV
IwNER'S NAME: PERMU ISSUE DATE
CRAIG SILVER 879 AZALEA DR. 4
NE: - - SANITARY NO. CONTROL NO.
(408) 377-8045
ARCHITECfENGINEER: - BUILDING PERMTr INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lop LICENSED CONTRACTOR'S CLARATION ]Ob Description
Zp I M y affirm Nn I am lime a mvivons of Chapter 9(commencing - p
<U testi IXIU7 of Division 3ofihc B and rofcssiow Code.and my license is
NmBr doff REVISION--IN HOUSE USE ONLY
2 Lice CI Lk.p.
Dam - Ca �m NO NEW PERMIT ISSEUD/ ORIG- - #0417100_64-_ '_
Z" "-
CHITECIS
a� 111`.�_nJ my plane shall W used az puhlie orris a
eau
3 0 Licensed Professional
OWNER-BUILDER DECLARATION
a� I hemby affirm that I am exempt from tW Canuacmh LicenseLaw(or the
Z
00 fallowing mown.(Section 701.5.Business and Pmromades Code:My city or county
X m C! which requires a permit to construct.alter.improve.demolish,or repair any structure
prior to its issuance,also requires the applicant rot such Permit o file a signed statement -
t?< thathe islicensed pursuant 10the provisions ofthe commemraLimaseLaw(Chapter 9 Sq.FL Floor Area Valuation
Ali-$ (commencing with Section 70M)of Division 3 of NC B usiness and Professions Coale)or Q
- that he is exempt therefrom ad J
the Was for r ancgcd exemption.Any violation of
Section 7031.5 by ary applicant far a permit subjects the applicant to a civil perulty or APN Number " Occupancy Type
not mom Nan five hundred della.(5500).
Q I,as owner of the potion.or my cmploycu with wages as their I.compartment,
will do the wart.and the structure is not intended or o0crad for sale(Sm.?Oa4,Business
and Professions Curie:The Contractors Li.Law does rat apply so an owner,of - Required Inspections ..
property,who Wildsor improves Hereon,and who doessuchwmk himselfor through his
own employees,provided that such improvemcna are notintended oro@red forsale If. ., - .-- --- -
hiLticr Neavetng burden of
wt he did.ane year ofimpove for eowner- -
builder will have Ne burden of proving that he did not build or improve for purpose of - -
sal
0 1,1,construct mvear of ct property,am udus and contracting with OccwM comracm.m -
mLatheproject(Sec..an Business and Professions Code:)Mus Contractor's Lt., -
'<eme law dmf no, a an owner of property who Wilda rs improves theman,and
whence La contracts for such Ptoleas with acanvactor(s)Iiaved Purswm in cm Convxtoh -- _--License Law.
❑lam eacmptunder Sec. .Bh PCfor this moon
_ '
"wnen Date WORKERS COMPENSATION DECLARATION .'
1 hereby affirm under penally of perjury arc of the following declarations:
❑I have and will maintain a Cerifeam of Consent to selGinsuie for Worker's Cumpcn- "'-'—
section as provided for by Section 3700 of the labor Code,for Ne pesfanmanm of in, '
wank for which this permit is issued.
❑I have and will maintain Workers Compensation lom.o ,ss mquimd by Section - - -
3ID0oftheUbor Code.far Ne p toramancnrf Ne work for hich Nis permit is issued.
My rker's Compensation lwmance career and P 1,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
phissection paidnotbeeamPlelcd ifthe(varminforoneivalmadollars(Sla) -'
m less-)
1 cenifv Not in sae Perf...a of in.wy It for whim Nis® it u issued.1 shall net .. --
employanY o' onYm a waz fi C me wblcct 1otM oheni Compensation
Laws ofC a / -
an
IC O APP 1 ,afro making Ccndcam of Exemption,you should - - - -
rnme subject t cWoher's Compcwati provisions of the labor Code,you must
roahwith comply with such pinvestors or this Permit shall W deemed revoked.
Z� CONSTRUCTION LENDING AGENCY --
'r. I hereby affirm that Jacm is a eowtruction lending agency,for Ne pmfufmance or
Ne wort for which this Permit is issued(Sac.309].Civ.CJ
[gl Q Lenders Name
D z lender's Address
U O 1 certify that 1 have mad this application and sum that Ne atom information is
ti.P cornea-I agree to comply with all city and county ordinances and sate laws.taring in
0U Wilding cowwction.and hereby authomempressenmtives of this city to enter upon Nc
r a
have mentioned property for inspection PurPwos.
(, gy (We)agree to save,indemnify and keep ham less the City of Cupertino against ,t
N Iiabilitiu,judgmenu.eostsand apcnws which may in any way accrue against said City /
U Z APPLI�mNTCUNDERS'T N.(thisAND WIL COMPLY WITH ALL NON-POINT Issued by: Date
RE L%TIO
�2 ('� Re-roofs
' ger f APP1mHAZA OUS MATERIALS DISCLOSURE Data
Type of Roof
an
Will lie applicant or future Wilding occupant store or handle hazardous material
az defied by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
- Cade,Sperms 25532(.)? mw_ All roofs shall be inspected prior to any roofing material being installed.
Will the air moraor rmum building by the B care Area
Air cm or Marta which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air conmminenu w defined by the Bay Arca Air Quality Management all new materials for inspection.
District?
p Yes t
In
a,ham read the ha.Nous materials reyvimmcnu under Chapter GYS of Nc Califor-
niaHcalN&Safcty Code Swdons25N)5,25533ud25534.iunw rend Nairlhe Wilding
Jars not a manly ham a mnanL Nat it u mY mspowihilitY m nodl'y We acupwl of Nc
yu' nu chiIpriorto issuance ofaCertifies.ofOccup cy. Signature of Applicant Date
per wmorize .gem Dam G All roof coverings to be Class"B"or better
Y