00100126 CITY OF CUPERTINO
InAl,I)ING DIVISION PERMIT CONTRACTOR INFORMATION:
FORMING ADDRIESS: PERMIT'NO.
22,372 lvlC C'I...E]...I nlq I:M INC 00.1,0011;:211ti,
OWNER'S NAME: APPLICAFTON SUB DAIII,
01.3E.111 17:1.6 E)1131,11.7 AVE: 0EE, :I.(!1/18 r',20
PHONE (408)29!L_� SANITARY NO CONI ROL.NO.
O.Z ARCHITECTRNGINEER BUR.DING FERMI'I INFO
00 O
.E BILDI;I.ECT PLUMB SUCH
g Z�
z ls 5 Z_ brmb,xIlACLNSpD CON'TRACTOR'S RACTOR'S DECLARATION Job Description
I
Z . no that lain licensed under provisions of Chapter 9(commencing
whhSC�111)�7(X)())()il)Lvisit)n3ottlio[3u� zinc 11-I'veon,Ccall.kind i"o'e
I, folliom,arandchno.
,
NSDam I.icr.w'Cla,,_ I'mers
NgS.a,to [late Comm,har
AIRCHI I pC I'S OF(i.ARXI ION
I modersound on,phei-xincill be no,al a,public mend,
Ul,oned Profe,,knel
than
Uhc[.ARXFION
1 hereby affirin bar I a,,, wit,from he Cantractnrl U,mn,c Lan, Ili, be
following mason,(Section)031.5.Huxiaremsand PrefictsionsCork:Any city orcounty
which respire,a penin,,,corouro,allcr,improve,deteelfid,or repair any structure
i Cam Ili.,it,it,lwwanca al........ml dila"phlron fur such'I all III i la 11,11all%all,necto
pop he is licensed purnearm it)the powbion,of the Contractor.License l(Chapter 9 Sq. Ft. Floor Area Valuation
(commercial,with Section 7000)of Di%mons 3 of the Business.and Profession.Code)
nr pro hen exron,ps ibriefn n and me,hali%mr the allied plallipfion.Any violation Occupaa.ncy of Sectian 7031.5 by any applicant It),a a....it abl I I
.,pli,t ,a ,III ,nally
of not more man five havidend dollars($500), APN Number
E3 1.avow car of the Prnpeny.zit try c,o,l,Yc,,,ho,,It wage,a,their hole cannpresidual --t ep f-.R i P (11111
will do the stick,;.ad Ilhe x1m,loure is it,), me,uh,l] ,,allied fir, at,(S,,.7044.
Business and Pftais%iors Covic The Commi License Law durs not apply to an Required Inspections
ovicroi prupenyWhohold,or improves thercon,and ishoduc%such work himself 7
nr through his own employee.........led hat rich inproveriect, ars, of intended ,, 1.0f .WE-R & Wn*rl: 11
ollemd lor Ile.ll:howeve,In,building ,, .I......ennen,I,wild within u, anuot 202 E -11-1-1111YElIG
compIctiourflus,nismer-builder will have fluchumearodprovingim,he did at),imildor
e Ul D Rl J_OC)l� I
improve(,it por.1'sue.). 301. 1;:OLJ(*.,jl-1 rI_umr3j,w3
01,us owner of the property.ooh ast ouua,fia,with licensed conunmon,to
currunno the project(Sec.7(W.nt,ine,,and rrok,xim,a Cod,01fic Compiler', 301? TUD & 01:2 E3110LI
License Law does tic)[apply to an owner of Mo,my who budds or improve,thereon.
It,, ountrol, lo,set, nujr,I,will,I,c,armrIuf,) puraram ,,the 03 FMUGH ITIE"CHAIII11CAL
Con L.i,ea%c Law.
304 1
0 1 am exempt under Sec._.8&P C comms claw. P!OUGH E:11:C*FR1C()l
0,ner—Date .402 FI1,1AL 1-11—UlIB11,10 E:-'I%IERGY
WORKIIR'S COMIIHNSAI ION DECI.ARNI ION
• I larely afficar,and,,picialty,il perjunona,III he roll—leM declaration, 507 F-11,1AL PLUITIB11,16
0 1 have and will al a Certifican,or C iwu( ,, ell.i.,um for Work,,',
Courn,sensemor, as provided for by Section 3700 of the Until Code, lot the
,crioncence of[lie work lot which this pennit is issual
E]I hall it will tomm;....Worker's Com,enranon Insurance,as repriced by Section
37BO of the UK.,Code.fill the serrommunce of he w...k for hah this .it is
issued.sly W'orker's Con,pervanion havarrove carrier and policy numathlr am:
c.ie,:_Fairly :
CERTIFICNI ION OF EXEMPTION FROM WORK12RS
CONIP17NSATION INSURANCE
I Buis leholl need our Net conol,leted it ILw crink is fisc one hundred collars
(11001 In,,.)
I ,natty [,at in lie w.or unec or it,work for ishidt flik Parma Is Iuue4 I
,hall not employ any pecan in any manner so Its%I)become subject to the Workers
Coulloinvinvoin Laos%ofCadformin[late
Not
CE[0 AIIIIIACAN 1:It.anwi-nnaking tlhls CendfiColl ill Rxecrtion,You 41culd
thexonn,�umjavt ill he Necukt,"C.sn""mi I poomomol the i.alnor Coda, ourrativi
Z 0
— forthwith comply with such provisions or this permit shin be destined resulted.
,NSr rRUC1 ION LIENDINO A610CY
4 1 hereby aftintrU them I—cotramation lending agency for[tic crontance
> of the vink(I,,which this permit is issued(See 3097.Civ.C.)
E 1,emar'%Name
96
z L,ank,,Address
U C) I cerfily that I have mad this application and state that the above information is
;t, ;: loreco.I alum.u,comply.,In;Ill lily and..mm,milintarce,and sum law,reltifiri,
LJ is bidding co tacit It liershy auarui,,.�'1II;LIl1r1 of this'Ill 0 cull'all'.
W (be abive-menlioned property for inspection on Purposes.
96 (We)agree to save,indemnify and keep harrallev,the City of Cupertino against
14 leinlair,,jtmI roa,and cs l,cmcx which Huy in an,way a,,mc a,aiav said
Cn,in ctav,a,laale of'he'trann,ol fln,plot...
APPUCANLI UNDERSTANDS AND WII.L COMPLY li AI.L NON-PORI Issued by: Date
SOURCE REGULATIONS.
Si,eatumot Ar,itlentiCanualit, Oate Re-roofs
HAZARDOUS MATHRIAE-S DISC[.OSURH
Willdic l,piwaillor Whom builden,cip.,vol xameor hat hananion,ralimmil Type of Roof
a,drfined by tic Cupertino Municipal Ons,Chapter 9.12 and me fl,ahlband Safety
Code,Section 25532(a)?
0 Yea 0 No All roofs shall be inspected prior to any roofing material being installed.
W,l he It......it.pure bpEmng n.capant ata enalp,mml W cavils,whi,li [fit roof is installed without first obtaining an inspection, I agree to remove
"Inin 161-c!by the lie,An.Art Qbalay Isfuna,cou,,la
Dwriepl all new materials for Inspection. Applicant understands and will comply with
OY, 0 No all non-point source regulations.
I have read lic Iniondo-coulcrials orlairennants;under Clcpamr 6105 of tire
Calif...ll iHealth&Sale,,Code,Sopron,25505.25533 and 25514.1 undersand Thal
if he building does net correctly have a tenant,that it I%as,m,,mn,,hiI it,to notify the
.spam of the erotic......I,which must be met prior n,sxuance(it a Cerlificam of
Ov.paal Signature of Applicant Date
Own,, ,,i ho,!,ad gnat timeAll roof coverings to be Class "B" or better
-OFFICE
CITY OF CUPERTINO PERMrr NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADD.^.ESS: t' -{,. Spy TARY NO. 1 TO SU MRTAL OAT
63ok i�i.9lnazni zlJl� 14f�lhi�€,
OWNER'S E:ocix4t
` NI CONTROL
ii, SGvtiG 70CSV7i1�(esTSils E E 10/18/2000
ARCHITECT/ENGINEER (@ ) 2t-7767 5-7767 BULDING PERMIT INFO7z We "
�00
LICENSED CONTRACTOR'S DECLARATION
Iharebyalfrm Netlam liccnscd under provisions of Chapter9(commercipg Job Description
Foe°w with Section]000)ofDivision3ofthe Lic at eaandProkniowCode ror bceemi. 0 (C)
Q Y J is full force sed eBec '�l!
wO i U Li«n Clan Coned
;LL N Dam Conuecux
LL O S ARCHrrF,GTS DECLARATION 4_
1 undenuiM mY plans awl ha used u public rtcads V
re�o`o
Licensed!RoressiotW
list lam ex[LDERempt
DECLARATION
�Z Y I hereby aRmt that I am eaempr from the Contractors License Law for the '
��o follouin8 rumn.(Scmion]OJL3.seines,end Nofmiom Cude:AnY city a county
a 3� svnich reyubes a peemit in construct.alter,improve,Ocmolish.or raw any stmmme Sq. Ft. Floor Area Val ation
priato its issuance.also requires the applicant f«such pmrdl to file a signed sanctioned
Wr ha is IittmN punwnt m Ne Provisions olds Cmtraaofs Licrna taw(Chaps 9
uotmnenangwithsection10003mmNeionJortheeaaine.aaadproreaaimacoae)a APN Number - Oc p C Ty e
Nat he is exempt therefrom and the India for the alleged exemption.Any violation of
Section 1031.5 by any applicant for a arms subjects the applicant to a civil penalty or
am more Nen five hundred dollen(S3001.
❑Lanownar ofdspropeny,mmyempiny«swiNwagcsmthdrwleeontpematim. 3560'Q ila :pectlons
anal Bothe work,and : wmtum uumimeadedor .doff«We(Sa.i sto Budmss
and property
whom Cade:The C shares I.ianse law ileus not apply to lf wtrr of
his me whobuilds nr improves t suchisadwhodas such wakdedar Of through 106 — SEWER 8 WATER
his own employeca,provided Wt such impnovemc within sold art na iyeaMd a ,leered for
side.¢bnwerwillhavetheburimprovemengthatheione ya,rarmprove n.Na 202 — UNDERFLOOR PLUMBING
owner-builder will love the burden of proving Net he did no,build or improve for pur-
pouorwe.). 301 — ROUGH PLUMBING
❑1,an ow«ror Ne property,am cacmaively contrasting with Innamed!conned,.to 302 — TUB O R SHOWER
construct the pmjmt(Sec.7W,Business aol Professions,Cade:)The Contractors Li-
caxLaw do"ren apply manownerofproperty who heildaorimmovasthemem.and 502 — FINAL PLUMBING ENERGY
who contracts for such proje«s witha commissions)licensed pursuant an the Canoactors
License Law. 506 — GAS —FEST
❑lame.emptandersea. .B&pCmrNixmw. 507 — FINAL PLUMBING
Owns, Dao
WORKER'S COMPENSATION DECLARATION
1 hereby affirm ander penalty of perjury one of One fallowing dala.uiam: '
I have am will maintain a Certificate centered to self-insum far Workers Compere
cation.as provided for by Section 3100 of the Labor Cade,for the pedomunKe of the
ink for wnicn runs permit is issued,
1 have and will maintain Workers Compensation Insurance,as required by Section
W of the labor Code,for the performance of the work for which Nis permit is leaned.
Y'. er ,C pen io Imo ance cern and Policy �q n
Cartier; Policy No:
CEFGHFICATEOFEXEM ONFROMWORKERS'
COMPENSATION INSURANCE
(This,ansa need me bccomPlercd ifthe'now is forme hundred dollen(SIM
or le's.)
I certify that in the performance of the work for which this permit is issued,]shell
na employ any penon in any manner ao n m bewme.eubjano Ne Worken'compere
ntim law.of Cdiforeia Date
Applicant
NOTICE 1'O APPLICANT:If,after making this Certificate of Exemption,ym should
become auhj=I to Ne Workars Compensation provisions of the Lehor Cade,you must
foMwith comply with such provisions or this permit shall be deemed re,Am
CONSTRUCTION LENDING AGENCY
Q Q Ihcmbysffmt Nat there i.a mmtruaim lending.,.y fa m «
the perfoanof
',L the work for which Nia permit is issued lga.l09].Civ.C.)
F,t 4 Leaders Name
y > sad rs Address
W1 certify Ner 1 have read this application and won that the above information is
Z. Qcol agree to comply with all city and county ordinances arta suite laws mining to
Z mm.building construction,and hereby amhodm npreenutives of this city to enter upon the
V above-mcntimad property fa iapeelion purposes.
W F„
(We)agree m urs,indemnify and kap batmlua the City to Col"moo.gsimt
V liabilities,judgrsnts,cosrsaM expenses which may in any way source agents said City
} W in conaqucnee of the gents,of this permit.
[r S APPLICA N UNDERSTANDS AND WI LL COMV 11H ALL NON-POI
V SOUR ItE.MM A
Dc¢ant, onuacror Data
RDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupsm at=or handle haaallons mound Re-roofs
as defined by Ins Capeninn monpal Code.Chapter 9,12,and the Health end SafetyT e of Roof
Code.Section 15532(x)? yP
[3y., Nu
W ll the.ppI turf are Wilding«cap.ta,e agaipm nt std ices which All roofs shall be inspected prior to any roofing material being
mit hanrdme,au comumber as defined by the Bay Aro Air Quality Manaporem installed. If a roof is Installed without first obtaining an inspection
oYC9 �rq�`3I agree to remove all new materials for inspection. Applicant
lhave road Ne dmeivterida rtgnim Chapmr "of ds Cali- understands and will comply with all non point source regulations.
fomen&Safer ode,Sations 255113,253J u253)4.I undvnend Net if Ne
Mrild 'All sac h e ,that it ism mibili mtwtify ac pant
ofN n r run f ificem May 1t9
v E Signature of Applicant Date
dwm— dwumed• t I Q Gone
All roof coverings to be Class"B"or better
OFFICE