00030043 CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: Qo 030 0 ' 3
BUILDING Z /,WO� )�1'
`����' a C� (/' y� r SANITARY NO. APPLICATION SUBMfITAL DAT
A/ w n0
OWNER'S AME:.. , / {l//
DGIk an SHeV l NIC CONTROLp
Ad 9
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Nre4-DO I -2,6 ❑
CHITECT/ENGINEER BULUWCI'ERMIT INFO
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N 7 LICENSED CONTRACTOR'S DECLARATION
I hereby ti inn that 1 m licensed under provisions of Chapter 9(cotmeeing Job Description
C u� withgation T000)ofoiviainn3nrtne BusincvsandProfesaiomcode,and mYlrcensa is / L
qsee ;nfull.CL..dcRcn. 7.-,
O /n/ trC�i�
a O ii U Liwnne Class Lic.N !/fGri'f .JeN✓'a-
Contractor— M
3 c H D1,—ARCHITECTS DECLARATION ./�,f "�/Le I /� dr ��
C= g I understand my plans awl be wand th public acwda m�P S.n/�
W 6 z Licrosed Prof<ssiow
HE
OWNER-BUILDER DECLARATION
-Z¢ 1 hereby aW.that 1 am exempt from the Co utracmrs License Law,fm the
G following tem..(Section]031.5.Busin as and Professions Curie:Any city or county
wt3$ which"tines a period an rmabu. lco
,after,improdemolish,
improve. or tepnu any stmcwe Sq. Ft. Floor Area Valuation
prior to its issuance,ahr.quireh th<apphcant for such pemtit m file. igned augment ODO
that be is licensed pursuant to me pmvisions of Ne Contractor's License Law(Chapter 9
Wrimencing with Section 7000)of Division 3 ofthe Raiment real Prefeniomcode)m ppN Number occupancy Type
But M is exempt thertrrom and Use wis fa me elkg.l exemption.My violation of ^^
Section 7031.5 by any applitenl for a permit subjects the applicant to a civil pewty of 3 2 Z 00
m man Bve hundred drllam(550(1).
`JQ�°JI,^,a.w„m nrme p,.p<„Y,wmY employe.comm w,gea..me;r.nle<.mpem.t;e, Required Inspections
and dothework,Coe:no ore;snot intendedo Law len fwuk(Sa.]O-ownercof
and Property
-mom Code:The Con thereat License Laws not apply m lf owner o/
his o nY coal builds w impmva thSuch i and who deco ouch wwk himself w through
his own employeese provided r i ouch improameu thin on)method a ofttial fm _
salt.If,howevw the building ur improvement Is hold within one yevofmpsome for par'-builder will love the burden of proving that he did not Wild or improve for wry
post of
❑L i ower of the pro.71)1 em Ciness and Containing Cod licensedThConoo-anors t.
ca..Le din I (Sartoan,wnerof andrty who
oho Code:)The Contractors nd
cense law deco rot apply je ts own.of property wbo ad,Ih w improve comma, e" -
wMnse Law.fm each projects with acwntractw(s):)canoed pursuant to meee.R.cmrr O
License Law. O
❑1 am exempt:unacr S .B kPC for this an
Owner Dema/7 w
WOR COMPENSATION DECLARATION - -
1 hereby anon der penalty of perjury oa of the following hclamtiam:
1 hast end will"moron•Carola,or Coluant m self-imme,to Workeh Compen-
tion,ea provided for by Section 37W of the Labor Cock.for the pori a of the
ork for which this permit is issued.
❑I love and will minimum,Wollner.Compensation Insurance,as required by Section
3700of the IaW,Cade,for th<performarrce ordc work for which this permit is island. .
My Workers Compensation Insurance canicred Policy number a.: _
Cartier. Policy N.,
CERTMCATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE
(This section need no hcompleted if the Permit ih for Wehundred toldit's(SIM)
or las.)
Iccniry balm the pay Winner oldie ato
for which this peanuti.ont'C Isha11
not employ any person in any manner so as to hecome subject me Warkere'Compo- '
union laws of California.Dau
Applicant
NOTICE TO APPLICAM':If,after making this Certificate of Exemption.you ahmrM
become subject to the Workrrs Compensation provisions of the Labor Code,you most
forthwith comply wit such provisions or Nis pemtit awl be dared revoked.
CONSTRUCTION LENDING AGENCY
(] Q Ihereby aRmt lw mem is a commotion lending agency for the prtomwce of -
Z me work for which this peanut is Issued(Sec.309],Civ,C.)
t~, 4 Lender's Name
ya > landar's Addmnw
f� I amy,tw 1 has,read this application and auto that the shove information i.
M conn,I agree to comply wit all city and county While.,and sum laws sluing to
w7 Z building consoucuon,and hereby mahraian mpreaenutives of this city to enter upon the
U 0 above-mismimad property for imprint.purposes.
W. t;,r (We).gree m ntvr.irWantudy and keep harmleha the City of Cupertino against
0 U ludilitirs,judgments,trio and aspcities which may in any way acerae mistral said City
} ILL in consequence of the grating of this WRj.
I [� ly APPLICANT UNDERSTANDS AND WIII.COMPLY WITH ALL NON-POINT
U z SOURCE RI:."IATIONS. /r7
S,Wm.o l;c..,-W no pate
HAZARDOUS MATERIALS DISCLOSURE ( V
Will do.,Rcentortutu.Wilding acupant.tm<rr handle ham.drua materiel Rf-96ofs
as defied by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety Type of Roof
Code,Section 25532(x)] YP
❑Yes �No
All roofs shall be inspected prior to an
Will the applicant or future Wilding.ccupant use equipment m devices which roofing material being
omit huratdouh or conumitunu as defined by the Be,Arta Air Quality Mainstalled. If a roof is Installed without first obtaining an inspection
D.onct] I a ree to remove all new materials for inspection. Applicant
❑Yes No
a e..dth wad oma ri...gwimm nawnd rCh pt 6.95rfm �.;- understands and will comply with all non point source regulations.
rol.0 Hralth R Safety code.Sections 2aw5.2.33)sed 255Jn.I undmoed thu if the \ �'v /242000 y}/�D.lO
building does nee currently Iteviceun tw it is my responsibility metiryde«cupant / V
of the aqulre which min rico m ihxuaee of
a pp��il"me of
3� Signature of licant Date
nr,mau agent Dau
All roof coverings to be Class"B"or better
OFFICE
i
!-APPnCVED
IN ACCORDANCE WITH THE CITY OF
Oy )ACUTEPERT a::CODESMD ORDINANCES
' iIGNED I' --
j f%s set ul rc, ; :.t' :leclfications MUST
j kept on `i: , ^a: ...1 times and it is un
� ZI' lawful to m.... .� -;?e5 or alterations
on same
wit I a r1rmission from 5}
the building u, i .; of Cupertino.
The stamping ur s P 'h.';nd snecdicat ons T 18}
21 SHALL NOT be lw.cP. <im or ; an
I approval of lila violat n i am a ' iow - -
`II� j of any City Ordinnna TOIaET1 - i- - -32 -
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J MAR 0 8 2000 D
1p 497 Lockwwa{ 17rr've NsT '3v
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Dwg no.
NONAME Scale:maximum Design: 03/06/00
All dimensions 8 size designations TME This Is an original design and must Date 03/06/00
given are ubject to verification on HOME DEPOT not be released or copied unless chaff
job site an adjustment to at job applicable fee has been paid or job Designer
conditionsi order placed. LARRY FORD
i