00050099 CITY'OF CUPERTINO PERMITNO. QQ
BUILDING DIVISION PERMIT -. CONTRACTOR INFORMATION: Q f9�
BUILDING ADDRESS:
4.
' ' SANITARY �AP�PLICA/O�NSU rITALDA
TE
0017/74
O/1VGT�OW S.NAM46 ra NIC CONROL%O (
O O / • , P'� ❑
ARCHITECVENG. �� P(ff BOLDING PERMIT INFO
z
ZO?25 • IM1ertbY eOitmCENSE�eoN CONTRACTORS DECLARATION
(mnmme«ung" - ' e fob Description
oN—a..
t,—Cu wish gucion7000)of on Sof IsctheBusi«an C .aMmy littnrtu
6 y Sa Q' in full(oma dellen V /��1� 6 r LttL,,���
6 uttll.e ue:x
Dalc' cnau«mr .. .
t a O j ARCHr1EC1'S DEC -
'now
1 side lend my'le as shall he used ss public rcmrds
a <o - -
n.Oo Licanned Pmfeeximud
vl^_,y .. OWNER-BUB.DER DECLARATION .. -
n I M1. .(Ben on 71 am exempt from Ne Come.Co Lice y'taw cu the
S O following mama.permit
7 o L3.Bui ar. and profession.dom ou Code:MY city m county x
prior
r t its issuance.
s e e.also m cures the alter,i t for such
h cmut t or mash end mincemeat
_
3 �� ,.S" t. Floor Are �O g y.�l ion
.
priorto its issuance,Jso mamma the applicant ouch pemdno file uigned slammem `J � V tl
thathe arixlicemeit pSeswnuo the of Division
Sof Contractors Licrnrt law fCluqu9
.(com a I.exempt
with Section 7(m))ofDivision 3 of the Busmen epr c..fmi.sia
Net he I.exempt Ihacfrom and the buns for the alleged a I,c t to Any violation of r--s P Numbs Occupancy Type
Section 703L3 by anY ePPlicmt for a permit wbj«u the epPlicmt to a civil penalty.( /J•
O1 more Nen five hundred dollars($300).
I.axown=r.rthem.pear.mfuremPlnycexwildwags,..tmir.alaramPerowan, Required Inspections
will do Ne work,and the s"cmrc is nor intended or offered for We(S«.7044,Bus re sr
and Profusions Code:The Carmanori Litto.+e Law dans non apply to m,nmer of
property who Kilda or improves thereon,and who does inch work himself cur through
his own employees,provided that such'impovemcnu ell nn inlmded«.R=ecd for
sells.If,however,the Wilthng or improvement la sued within me yrox.fcompletimi,the
owwobuildcr will have the hoiden of proving that he did ret build cr improve for pur- -
poseofeale.). -
D 1,u owner of the property,sen exclusively conauring with licensed conlnclon an
construct the project(Sec.7044.Busing end Profusions Code:)The Convectmes U. '
.lesion law does.1 ply he m.wner of property who build.or initiatives Harron,and '
whence Los ch q
su .j«u with. licensed pursuacontracontractors.IM1e contractors
License law.. e
D l un exempt under S«. ,B Ar P C for this eesson '
Owner Dam ' MAY 2 1 2001
WORKER'S COMPENSATION DECLARATION
. 1 hereby affirm under penalty of perjury oro of the following d«lmliou:
[]1118se aril provided
by a timi 37 K of the Lab to ode,farther,
WOrkere C.I11Pem• r BUILDING,motion,ss proaldri for by 5s ism J700 of the Labor Code,/.sides peAomuntt of the BUIL®I NG.
k(av and this pemitis iu.ed.
❑I love am will maintain Wohefs Compensation Insurance.as,rtyuimd by Section
3701).Dthe boa Cade,far the pe r sof d work for Which spennn is issvcd.
My It. nil I •off ce 'tr ggd c -
Curies �Mdx/p��9^p� L .
CERTIFICATE OF EXEMP IOP FROM W0 KERS' r ,
MPENSATION INSURANCE -
(Thias«i tt X111,,//���r,,//,,,,,�,�/�1(liy(/fjy Je//�1lodrN dollua(SI00)
Icrmfy per int in pe rmmc h theWllucco*C, pan-
' all
not employ any person in my manner m as to become xubjmno dm Wodusa'Compen-
nlionLawso(Celiromie.DueApplicaut
'
r•
NOTICE TO APPLICANT.If.e.aper training this vi,i ms of of E idaur Cod You.M1ould
hemme iubb comp m the Wortr r Come.or this
.it
ioas of the labor Code,. mon
• forthwith comply with such provisions or this pemminlWl ba deeemmd revoked.' � -
• O
Z CONSTRUCTION LENDING AGENCY
.O Q , .I hereby ulGmm then then is..., do.lending egmcy for the perfo.a of
bthe work for which this permit is issued(S«.3097,Civ.C.)
. '
i.y Lendi None
r.( 7 Landers Address .
W ^E I certify then 1 hive lead thus application and state that Ne above information
Civ coyest,l agree to comply withJI city slid coanry tiNinancer roil sur laws relating 1. -
Z buildingcnusexa on,and lmeseby aathmiu mpreamlenivaofthis city to encuupon the •s
V movalmnlladed property fn impaction puspoam.
fire.f" (We)agree to use.indemnify and kap hennlesx the(24y of Cupenire egeinst
r,J liabililiex,J.dgmcnls.costs andexpensss which may in my weyaccrue atriums said City !^
t,Tl iocomcge of the grmdngof Nisprtmit. '
QAPPLIC N7 UNDERSP ❑S�kN .'
ROPLY WITH ALL N N- )INT
U Z SOUR I O 1 ,
gig of A'plieenUCoI Dole
HAZARDOUS MATERIALS DISCLOSURE
Will Ilia applicmt or future building«cupmrstore or haMlls haardoda material Re-roofs
as defined by the Cupn4no Municipal Code,Chapter 9.12,end the H W N and Safny
Code.S«tion 23333007 Type of Roof "
❑Yes
Will the app]irmt.a ar oWilAing«E.penl use e9aipmcnl or deNrer wM1irh All roofs shall be inspected prior to any roofing material being'
emit h.'xirdoux sir mnuunimm as defined by the Bay Alda Ah Quality Management installed. If a roof is Installed without first obtaining an inspection
• District] I agree to remove all new materials for inspection. Applicant
,DYu - Nn d
In mad ehuardwamaural. understands and will comply with all non point source regulations.
�.rtmmp a d r Chap 6.93.!h Gali- P.Y P g
_ fomiu H &Salety Cade,g«vmu 23303.33303 and 2531G.I nide al i(Ne
Wild. ...ma lyhew t len,that it ismy nspomibiliry tt9gn fy cu sit _
al mnvhichst titin to iuuarce o(e CailYE ie y
ow th gent fL�" Data Signature of Applicant.'.. Date ,
All roof coverings to be Class"B",or better
OFFICE .. t,