00050024 CITY OF CUPERTINO PE/RMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: OV�SOfl2
BUILDING ADDRP.SS: ��j. �� /9 ' r, tiler U1I} W Y(/ � SANITARY NO APPLICATION SUBMITTAL DATE
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ARCHITECI'l1:NCaEER / 'W✓/✓V 64 AIRIF ❑ BIADING PERMIT INFO
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6th
r LICENSED CONYRACnder p DECLARATION
zz=C I hereby eRrm that em licensed under provisions of Chapemec
Chapter 9(cotming Job Description
antro wiNScc[ion oOW)of stun of Busmcssmdlunfcuiour .and rsylx rows
< `J In full force and eRat , �/ ��/�/� ///n D//' //n D
xowu U, c UC.N / / U W#�e�G/ /gL�LY�
3 c u Dar Conuacmr
Fy p ARCHITECT'S DECLARA N
` I unders[uW my plans Mall be used u public
x00
mSmtb
uccond prrfesnirnel
c u)i Z O s,I a.oUnAER front
she ATION
I-z 1 hereby aRmt on I am exempr from Ne License Any c Lew for the
`F G folkywortwhich oa rc+sm(Section 703 Customer.
Business and Ne.darn n Code:Any city a county
3$ which requires a e.also m conswm,deer,improve,h parent
t.fi repair my nmcm d Sq. Ft. Floor Area V• uaJ.{ojy
Four to is censed e,dw rt u,dm the applicant for such pesmiuo files signed stwcmr 9 (/U
Net heiscing wis puntion 7 the pmvisinnsof the eHunner9License Lew(Chapter 9
(commencing estwlrhacrefrno000)of basis for o(threged eemProfessions Code)of AP Nunlb•r Occupancy Type
that he is cwmpr Nmefwm ant the amts for drc alleged exemption.t Any it penalty
of h /n P Y YP
Section 9011.5 by any applicant for a amduubjecss tlr epplianuo a civil pemlry of
pt mre othan five hundred dollarsWY
I.ssownerof Nepr ny.wmyempinyeawi6waMu Ncuwlecompe m, Require s ections
will do Ne work,and the steumure is not immtdedoroRaied fm We(Sec.]Odd.Business
and professions Cde:The Contractor's Licenw tow does net apply to an owner of
property who builds m improves thereon,and who does such work himself or through
his own employees.provided Nn such improvetnenu are not intended or oReted foras
We.If,howcvc,the Wilding or improvement is sold within one yeunf complWon,da
r.Wilder will have the burden of proving that he did not Wild.,improve for pus. /
pose ru W �j
1,u owner of the property,un exclusively crnvacting with littneed cano-acmn to
msvm the door
(Sec.orad,owner
of and property
who one Code:)The Convector's std O
w law da,notch pro to m owner of property who sed p n ort to the thercrac and
who ."w.for such projecu with a couhacta(,)licensed punmm m Nr Conhecmr s
uanw 1zw.
(]Tem exemq undm 5a. .B&PCfor this reason
Owner Dar
WORKER'S COMPENSATION DECLARATION -
1 hereby aRmm under penelry of perjury,one of the following dvelastions:
El
I have and will tnsivtain of<nincaa ofComenuo eelf.insua fm WorkeYe Compcn-
utim,u provided fro by#abort 3]W of Ne Labor Code,for the pmmowna of ted
for which this permit is issued.
khave W will tmmaln Workees Compensation Irnurence,at wquired by Nation
W of the Ubor Code,for the performance of the work for which this pevro t is issueA
MY Wrrlrer'atppi ion In}urgpce curia and y N.:n CI
Carrier: /� �// („TIE OF Policy Na:
CERTIFlCCO OF COMPENSATION
FROM WORKERS'
COMPENSATION ISURANCE
(This section meds be completed ifthe prmdt isfarne hundred dWlen 151 W) '
or Ica.)
I cenify that in the arfom,of the wank for which this permit is issued,)shall
not employ any person in any mneme to or w become subject to the Worker:Compcn- .
u tion Lou,of C.lif nnia.Dar
Applicant
NOTICE 30 APPLICANT.If.after making this Cenifcare of Eu o,don.you should
become subject to the Worker's Compensation provisions a the UWr Code,You most
forthwith comply with such pmvismass or this permit dual be dsmeri Revoked.
CONSTRUCTION LENDING AGENCY
I] p IhcrcbY uRtm thus Nem is mmnmcGon lending agency frnhe prrfrrmmce of
Z
Ne work for which Nis pmnit in iwued(Sec.309],Civ.CJ
landcls Name
7 I ,s Address
fy] E I mufy than 1 have reed this applicumn and sur that the above infomatlon is
d cotrtn.I agree to comply with all city and county ordinances and star laws slating to
Z Wildingeonsuuction,and berebyauthorira tepfeunlnivewfdtis city to tram upon the
f..) above-mcmimrd,many for ins,m6cm purpowa.
W F~' (We)agree to save,indemnify and kap harmless the City of Comenino agairmt
0 V Iusbilities.judgments,Coss and expenses which may in any way acme against said City
>. W in commwu uce of the grating of this Femur
f^ d APPI.ICANTUNDER ANDSANIIWILI.COMPI.YWTrHA1.1.NON.IMn NT
V f SOURCC REGt11A'fIONS. N Z
Sigwurt�plicanVCr sour Dar
H Ip USMATERIAISDISCLOSURE
sod nmfuurc Wilding occupanl store or handle hassNous mumUd Re-roofs
at defined by the Cupertino MunicipE Code,Chapter 9.12,and the Health and Safety Type of Roof
Cdr.Swim 0532(.)^ YP
0Yo Nr
Will the applicant or fact re building occupant acne equipmem or devices which All roofs shall be inspected prior to any roofing material being
each hmardms air comainiranu u defined by the Bay Area Au Quality Management installed. If a roof is Installed without first obtaining an inspection
am t,
❑Yrs No I a ree to remove all new materials for inspection. Applicant
Ihaereadtheh.,,.dmrmamal,m9ninmmannde,ChapterM195oftheCali understands and will comply with all non point so reereg/ulations.
torous Health At Safety Code,Sections 25505,25533 and 25530.1 understand Net if the
building Eves not cmwndy have sacnum,that it is my responsibility m nmlfy Ne naupanI f V
of Nc rtyuirctrcna h must bt�mm prig w iuuesa of a Cmificem y.
ignature f A I' Date
Comroreu agcm P.
All roof coverings to be Class"B"or better
OFFICE