00050196 CITY OF CUPERTINO - PERMrr NO.
BUILDING DIVISION PERMIT CONTRACTOR;INFORMATION: n�a C-O
a
Bit LONG ADDRESS: 1 v��� t rot-6; J l
7 � ly SANITARY NO APPLICATION SUIIMITTAL DAT
0WsNE . ✓"•/%/�� A/w/lenal Aa NIC CONTROL#
PHONC: ei9 9Ys - °
ARCHITECf/ENGINEER DULDING PERMIT INFO
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l5/0)29�32%�2 � 77?— 3azz�
G<
F O m LICENSE DC ONTRACnclerProvisions
Na
0 0=0 1 hereby a0inn at I m licrned undo psrovisions of Chapter 9(my, rse" Job Description
F,mCcc wire Section 7")ofMji.wu lofthe Businesamd fessions etre.an my transit
a s� inrwurtrce.rmeffa J
x O 6 V Liarse C ca Lic.N
3LL H Dmc C
1...u.O g ARCHITECTS DSDECA xr
I undenlane my plans shall Ee usM asspuL Pub reeds
a a c ,,[treed Professl«W
'u5^_ OWNER-BUILDER DECLARATION
1 hereby affirm met l am exempt from the Connacsoes License law for the
afollowing moon.(Section 703 1.3.Business and Profession Cede:Any city or county
u"1which"mon.xi mul m convect,eller,improve,demolish,in repair my sweNrt
0'3 L. prior to its issuance.also".I.the applicants,f«wch permit to fileasigredememem Sq. Ft. Floor Area a 2111
that he is licensed punuam to the provisions of me Conciseness License law(CTupler 9
(commencing with Section 7").f Division 3 ofdle Business and Profession Code)or
thin he is exempt,hoofrom W the breis for the alleged exemption.Any viobuon of A`Number Occupancy Type
Section 7031.5 by any applicaut for a permit subjects the applicant o a civil panaty of
not mmore men fve hundred dollars($3)01
❑ Required Inspections
w it I do Ne work,and the structure is and intended reoffered!for sale(San.106x.Business
and Profnai«u Code:The Comrwmr's License taw does no,anpply,o m owner a
property wW builds or improves mebeon,and who dura men wort himself«through
his own employees.provided chat such improvements at no intended or offered for
we.If,howevin me Wilding or improvement I.sold widtinon yeariffmcb leuon.the
W ilea will have dm burden of proving that he did n«Wild«nlp
improve for p«-
owe Four-
we.).
❑st us tweet of tt property,a�n exclusively convactim wick licen.m contrast«.t-
mwct the project(S«.7014,B«ilsua and Profession Coer.l The Convector's Li- /
tens law dao rot apply m an owner of pmpmY wed Wildr or impmvu maeov,sod
whence,U..f«such pmjae with acantoc,or(Olicend pursuant m the Conbulors
License Law.
filum<xcmp underBaa .BRPCfor this rtuan
Owmar Dam
WORKER'S COMPENSATION DECIA ATION
1 harebY.Rina under penalty of perjury«cc of the following declaretime:
❑I have and will maintain aCenificate ofConsnuo self-insure for Workers Compare
snIion.es provided for by Saturn 3100 of me Lahor Code,for the peff..c of the
/ workJnrwhich this permit u issued.
have end will mninuin Wnrkeh Campewtion Inurence,es bequired by Section
3700 office Labor Code,for the perfice Cance office work f«which this permit's factual.
Myirr: f C9yq-JayyrNj fcarriesand Policy nunhpyy"zvc/
M,wo (/-f�Y.V Policy No.: . F
Ir
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectionneedran hemenplecou Jthe xim.is twos hundred dollars 13100)
or Int)
I mmy that in the pertowence of the work for which chi.pmout is issued,l shall
nm employ any person in my runner m as to become subjecuo me Workers'Cort'..
.cion laws of cidifomia.Dae
Applicant
NOTICE TO APPLICANT:If,after making this Cmifcate of E.emption,you alnuld
become suninn to the Workers Cmnpenu,ion provisions of the Lab«Cade,you must
forthwith comply with ouch sm,isim.or chis imi,iliall be da oud mvokrd.
CONSTRUCON LENDING AGENCY
Q 0 TII hereby affirm Ow there is a comboxcuom lending agency int the perfomunce of
i yme work rot which chis permit is issued(San.3050,Civ.C.)
lander,Name
(yd } Lenders Address
2z) 1 Unify mat 1 have bead mit application and aline ten Be above ird.m.I.
G. zcata,.1 agree to comply with ell city mW county ordinances and state laws relating to
D Z building mnsvuNon.nM hereby wthm.ce,resenu,ivn of this ci,ym enrerupon the
U 0abuvcmemioned property for inspection purposes.
LT. P (We)agree,o eve,indemnify and kap hnmlesx me City of Cupertino against
U Iiabiucies,judgmems,come and expenses which may in my way accrue agvnst said City
} W in consequence of meg.do,of this perm.
(� 6. APPLICANT UNDCRti L\NDS AND WILL COMPLY WITH ALL NON-POINT
V IZI SUURCI':RI:GL�yr1I'I( %*
Sig,wurc pplicanVCon Due
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bulding occupant store or handle haamdous material Re-roofs
as defined by the Cupmun Municipal Cade,Chapter 9.12,and the Health and Safely
Code,Section M532001. Type of Roof
❑Yes No
Will me applicant or ffmum Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
crit harndtus air conWnimns as defined by the Bay Arca Air Quality Management installed. If a roof is Installed without first obtaining an inspection
°``°``"
❑Yes I a ree to rem ve all new materials for inspection. Applicant
I have cud the hvardou.No materials rrnuimmrds under Chapter 6.95 of the Cali- Un erste d / 'll comply with all non point source regulations.
Na Health&Safety Cade,Saxons 75505,23533 and 255M 1 understand mel if the
Wilding deem nm II he VC e,event,mot It is my MvNislb1111y to notify the occupant el� �Q
oflh,cl .. lbemnpn«,tunauctfecediucte rat y. -. �/
i —�4I Of Si�y tare f Applicant Date
zedegcv� / Date
y/ All roof coverings to be Class"B"or better
OFFICE