00030081 CITY OF CUPERTINO PERMITNO.
BUn.DING DIVISION PERMIT CONTRACTOR INFORMATION: OQ �3 vQ I
BUILDING ADDRESS:
GA /Q/d(/��N/ ryJs/� C� SANITARY NO APPLICATION SUBM TTAL DATE
( (( C NIC CONTROLX
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ARCHITEC'I'AINGINEER BULUING I'ERMI'1'INFO
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nc LICENSED CONTRACTOR'S DECLARATION
o I hemby affirm deet I am licensed under provisions of Chapter 9(commcrcing Job Des ript inn
�N�� with section TIXp) (Divi ion3rflW BusinasWRofmaions Code,and myliccveis {k ,/ �^
infuB farce`rR s � e�
w um CLu
o.X /
i LL o N Dem ECI'S DECr
InO 1
i v�a 9 1 undenad my Elam Na11 be used a public ee<mds /�Z
1 a Licrnd R
srofcmional ^
OWNER-BUILDER DECLARATION V O
t Z r I hereby aRrm Nal I am,mrapt from NLi
e Commica rs cense Law for Ne
S S c full..,rca.m.(Sodom 7031.5.Business ad Profaiom Cade:Any city or county
3 m which mgaim:a permit m ccrostmm
er,alter,ima.e,dumrfinal
ars al e my I— Sq. Ft. Floor Area Valuation
prom to its inuence.la resumes the applicant fm such parrot to file a signed satemem
the,he is licensed punumt m Ne provisions of the Contractors License Law(Chega 9 C�•VlJ
(commucticing with Section 7")of Division 3 close Business and professions Code)in APN Numb Occuanc
py Type
Wt be is exempt Ihaermm and th,basis for the alleged e,empfirn.Any violation of
Section TOILS by any applicant for a permit subjects the applicantto a civil prmlry of S/�f
rd come Num five hunthcd dollars(33(10).
❑1.aaawnerarNep.openr.mmrempaYaawiNw.ge,.+dmeirealeaampen,.dan. Required Inspections
will do the work,and Nr structure is nm imeraddoroRered for We(Ser.7044,Business
and Rofes.iom Code:Pic Comtrantor's Lianas law does not apply to an owner a
property who builds or improve.therem,ad who dos such wok himself or through
his own employees,provided that such improvements an not intended in offered for
ale.If.bowcves,the Wilding in improvement is said within come Year of eampleiion,use
caner-Wilderwill hese the burden of proving Nat in,aid no,Wild or imgave far par-
poseuf,mc.).
❑1,as,owner of Ute Pees.704 ,H eacluaively professions with:)MIN Commarimes t. U S I N E S S
an,dmpt the pram"'(ser.Two,Brines.d Prare,amnr edit:)The canaawra u.
cruise law dam con appy to an owner of moven who bund.or inmroves thereon,and
who contracts fm such project;with acon racm,(q licensed pursuant W the Contractors
Licmm law.
❑nun eaemptuder Ser. Data
P C for this mason LICENSE
Owner Dae
Wm under p COMPENSATION DECLARATION
1 hereby will moi undo penally of ueperjury oro of the followingnsuredecbat'.iess
Ca:
lMvemdwihs pinuins towed.ateof Coraent tocol(-insum far WokeraCampers- R��UIRED
Shan,as provided rte by Section 7'100 of the labor Code,fa the prifomnrwe of the
wok far which this permit is issued.
O I have and will ode,for Winters Compensation Iruuor which
h required by Sadiron
3TOOof the,IaWr Cab,for the pcaonnarce ofthc wet for which Nis permit is issued.
My W. Court,must irn nnadance a�dPolicy nn
Cartier: Policy No,;
C[ CATE O ON PROM R S
COMPENSATION INSURANCE
(Tbis section need tea becample d ifthe parent is/monenumWUM ddlua($100)
Or less.)
1certify Jamin Nr,myum summer
s t wok for which this pemNislaud,l Nil
no,employ any person in any manor sa u m Wcrn¢vhjamo the wrdten•Comp<n-
sation Laws of California.Dem
Applicant
NMCE TO APPLICANT:IL after making this Cenifimm of Esempdon.You should - 'rY /, - \
beome subject ro Ne WorkAs Compensation provisions of the labor,Cods.you mus, U I tj
ronnwith comply wits such provisions car this permit shall IN deemed resulted.
CONSTRUCDON LENDING AGENCY MAR 13 2000
z Q lhemby affirm thin Nem is a prnstrocdon lending agency for the performance of
Z tW wok forwhich Nis Osti red(Ser.3097.0¢C)
F. Ceders Name
CC > IedaersAdrt, Ay_
4s. 1 unify that I be {Itis application and awe that 0se above information is
6. zcermet.I ago.to comply with all city and county Ordinances and m sulaws saluting to -- - --
a Z building construction,and hereby auhodm mpaanatives of this city to enter upon the
U C aNvo-mrnti,,ncd property for inspection purposes.
kit P (We) Z.to eve,indemnify and tap hiumles,the City of Cupertino against
Q U lobilide,,rydgmaia,ema ad mpemes which may in any way.—a-gain-said Ci,y
i.comesumc,d the goodies of Nis Pemut.
(•' N APPLICAW UNDERMNDS AND WI LT,COMPLY WITI I ALL NON-MIM'
V Z SOURCE.REGULAI IONS. /
Signature cat Applicant/Contnc,m Data
HAZARDOUS MATERIALS DISCLOSURE
Will cu,,icom Or futum Willing occupanm,Ime or hvdle hasudovs mammal Re-roofs
m defined by IN Cupcnino Mmiclpal Cdc.Chapter 9.12.and the Barb and Sarcry Type Of Roof
Cde,Section 25532e), /' yp
❑Yr, 4W
Will an,aWlicml at future building occupant me equipment or devices which All roofs shall be inspected prior to any roofing, material being
cdmll havodous air conamituna a defined!by dre Bay Arca An Quality Management installed. If a roof is Installed without first obtaining an inspection
Diavict? [ a ree to remove all new materials for inspection. Applicant
❑Yes
I hem roti the hanvrdou,maarol,desuimmcnts rode.Chapter 695 of lk Chi- Anaiends andwill comply ith all non point source regulations.
rowHeel A Safety Code,Sections 25505,2s my end 25534.1 understand Net if thebuilding ,nm cutmntlY havetenunL Na it is DIY m,po mimes onmifY Ne mcuPmt
fd¢ vemerm h' mu- met pdmwiu rc eCmmficau,of IXc Percy. f Applicant Date
O ed sag � a
/ All roof coverings to be Class"B"or better
OFFICE