00050122 Permit CITY OF CUPERTINOPERMITNO.
BUILDING DIVISo PERMIT�t'�- CON(TRsACTOR INFORMATION: 000,S- 0 1 ZZ
BUII"DLS /! / Y ��Jt+^/ V �l %Lit./✓
SANITARY NO APPLICA'[ION SUBMITTALDATE
OWNER'S NAME �� _
ruonc.
ARCIffrECT/ENOI / p� '•/YV x BULDING PERMIT INF
�� • ,dam-�.� `�o�� G�- �/
G«
r❑i LICENSED CONTRACTOR'S DECLARATION / -
o z=C 1 bamby Orr ma,1 lions d unser providore of Chapttt•9(my It= is �//, ��/" J b DesC
withSa,imT00a-,-r '" ofineBusincsaaM mYliancir ��Y-�l/Y "'�`
y of,a in full farm aM cReet. !
Liceree Clw Lie.B
u.y F 'Dam `Convm ,r .
1.u.
0Q ARCHITECTS DEC0iRATI&ffVVV
-� I undarsuM my plans shall An used in public eemrds
Soo
o Lictttsed prior e.aiow
OWNER-BUILDER DECLARATION-
C >' I hcrcby affi,m shat I Am exempt from the Cocuract.e.Licenu Lew for Ne x
Y a following reaan.(Salim 7031.3.Bonino{old Peofaviom Cade:Any city or county '
s. which"U ms A permit m construct.gift.iorrov2.demolish,n minor any evucam S Ft. Floor Area Val t'
prw 1.its isauaneq also"Almm applicsn,for such permit.fila.signedetaacmcm _q' U�-p. Gd
that he is licensed pumuanvu me provisions of me Contractors Lianee Law(Chapter 9 6, `
Ialhe I.Anatolia therefrom
SaNan]OW)h Amex far oft he Butlrcu eMProfwioru Cmorof Ap umber ccu anc T e
WI io is 31.5 b mmfrom ant the Amex for me is do, exemption.AnY it Mnsim of !' yp
Schon]OSIS by my aft mAl fa.permit wbjats rhe npplicmt to.civil penalty a( -
pw mom Nan five buMred aollnm y Amp!. '
mommamr Orme property.in my anrtAMWwh.wagesumevaoleco ,B., m, Required Inspections
will dothcwork,Code: he Cimisnot imet. o Law
notApply AAn,Boniness
is roti property
who
Code:The Coe.the orh Lt...w law dm ter apply s lf owner of
his own who builds or immovea thereon,papal who dopa such work himself w,luaugr
his awn employees provided mat room improvements aR nut iy..f or da and for - +
sda -Wiltiveimebuilthe but impmvemcm lsmldewithindion demo improve for the
pwMFlmildtt will have the buNen of proving that he did not build m improve for put-
. pose of glen
I,u other of me property,.Business
s and canumting nim httneed conv¢ton m
construct the es not (ger.]800,Business and property
who
Code:)The Contractors nd -
cense law does not apply to m owner of property who builds or ant in the mama and _
who contracts for such ptojau with aconvutor(s)licensed purtumt m me contractors
Littnm law. "
I An,exempt under Sm. B k P C for this mason
Owner .. - Den`_
WORKER'S COMPENSATION DECLARATION
1 Mem.y illmai uMer parnally,Canfic of mpnlury m,of the following daclav s hp Co
I love and will fo by eCion 37 te ofC a Labor Cor1. k,for
for Wwkerance of e
tion,ns provided
for by Section 3]00 of the Labor Cade,fur the performance of the
work for which Nioued:
s permit is iss \ '
❑1 have ab this
mdnuin WsmsL Compensation Ireurence.in rAluired by Section
My Weroc labor pelawathe peAo save of the work for orbic.Wapermit isiasyed.
MY Works' f o�pensetion!neuronumber er .
C-RTI dCA OF E ran N FR( RKER
COMPENSATION INSURANCE
I nor sstjpI needy¢pplp�pyt��( pvpu ly/p amyy d"a d 13100) 4 .
or land 'ITm/�a" -
+ I cenif tin me rfo once o n h' l is lamed.!sod! t" -
urn employ any person in my manor m as to become mbje t to the Wmacoc Compery le.it.laws of ci lifomie Date
Applicant - -
NOTICE TO APPLICANT:If,after making this Cer iGeaa of Exemption,you should '
income subject o me Workers Compensation provisionaof me Labnr Cade.you mus, •s s
forthwith comply wim such provisions or this pc.I,AM[]be deemed mvokad,
CONSTRUCTION LENDING AGENCY
O Q
• Ihereby affirm rba,mere is a construction lending agency for the perfomunce of • .
mewwk for which this permit is issued(Sa,3097,Civ,C.)
I ,does Name
('L > lenders Address +
(z1 0 I certify mat 1 have mad this application Amid.,am that the above infommtion is - t
z correct,l agree to comply with all city and county ordinances and suite laws¢bring to ,
building construction,and hereby amhoris rcpdcs taivcs of this city to mer upon the
V Q above-mentioned property for inspection paroms" 's "
(We)agree in save.indemnify and keep hacmlesa the City of Cupertino against -
O U !memo;judgments,costs and expense which may in my way accmeaeamit said City
in comcque ce of me giontin8 of this mit -
0. 'A C UN DIiRSTANl'? ILL COMPIA WITH
(ALLL12 N-POII/71' -
U z. SOUR .1 ,1..1I1 _
Sign pp¢ant/Comrutw ...
HAZARDOUS MATERIALS DISCLOSURE
Will the.pplican,of forum budding rcmpanrnomor haMia hmandou,matefit ,Re-roofs
As pert
defined by the Cuino Municipal Code.Chapter,9,12,And he Health and Safety
Code,Section 25532(.)? t Type of Roof
❑Yes ..
Will the Applicant at future Wilmngocmpmtuse agmpmecuordcvirawhich All roofs shall be inspected prior to any roofing material being
emit hvallous air conumivnu as defined by the Bay Arca Air Quality Manegemcm installed. If a roof is Installed without first obtaining an inspection -
°`"°"'° I agree to,remove all new materials for inspection. Applicant
❑Ycs d
lhnv d:charardonscultural,mquircmentsuMe,Chapter 665ofthe CAP un erstands and will comply with all non point source regulations.
tom.1 Safety Cade.Saviors]5505.23533 roti 253]4.1 tsM mat if the
buddi leurrm,ly luveamnurn,Uu imy rcxpomibiliry naifY occupant
Of ".I aFl AY0nGE 0f I [y.
Signature of Applicant Date
ret or, Aem ale All roof coverings to be Class"B+'or better
OFFICE