00030052 CITY OF CUPERTINOPERNIMNO.j
BUILDING DIVISION PERMIT CONTRACTORINFORMATION: 0O(D 3 0 -,C)S Z
BUILDINGADDRPSS: (� ` _ ,♦ `- /• _ r
O CP tN /v/I[`'�'QV•(Y /vv�l/I0 SANITARY NO. A =AT1 UtlMITTAL DATI
OWNER'SN ME: / e>ifCl 't.li /au . IC1
( V N1 V NLL NIC CONTROLp
` P , ` /^ ❑
ARCHRCf/F:NGINEER �y BOLDING I'EIiMIT INFO
wE07
LICENSED CONTRACTOR'S DECLARATION
i=C I hereby eRnn
that l w licetued ender pmonims of Chaptar 9(commenting Job Description
P=1_m withSCCtim]000)ofDivisim 3oftheBusinen and PmPeuions Code.and my lsttnm is
ne a 04 d5, in full force and eRcn. /�/O nom/ A'2
y License Cress Lic.N tib/ V
LL y�� Date
ConRacmr
t,a O ARCHITECTS
DECLARATION
Itzirst, mutsshall be umd as public mounds
usS R or OWNER-BORDER DECLARATION
iZ a 1 hereby affirm that I am exempt imm Ne Contractors License law for the �"� /✓�
`F C following mason.(Section 7031.5.Business and Professions Code:Any city Ce County
S m wIUCN rcquira•pemlil m covwn,stmt,impmvc,demolish,or repair any sWclWe Sq. Ft. Floor Area Valuation
prim to its iasuana,also requires the applicant fm such permit w file a'i'red msemem �\
that he is licensed mumm to Ne previssonsof the Connector.License Law(chapel 9 Q� V
(cormancing with Section 7")ofDivision J of the eusircu and Prefeuiotu Cods)m APN Number Oceu ane T e
Nat he is exempt therefrom and the basis for One allerd exemption,Any violmon of P Y YP
Sectim 7031.5 by any appliranl fora pcmdt subjects the applicant m.6penalty of 62 _ / QO
pm mom Nen Bre hundred dollars(5500).
L as owner ofthe properl,or myempi exa,with wages as their sok compemmim, Required Inspections
willelo Ne work,and Ne moem.is CoW or
t imendoBercd «
for mle(S .]814,Buaimu
and Proteus..Code:The Con.Curr's Liaise law does poor apply to ne owmf of
properly who builds or improves thereon,and who dose such work himself or Wough
his own empley tax:
pmvsdod r imprisonment such imporcmrnu art m inunded m oBirnd for
care lf,howc will coetbuilding e hmnofviiuddwithin meyw 9f provetim,N- 6
owmnbuildn will hare Use buNen of pmvine Net be did nm build m improve for Pur-
pos1.asCoe IIA I.os ow of en propene,Business eaand conbactin8 with liansW cmuaca. i- \
Car.La c m rm (Sac.91k1N, ..oand PosProperty
who lao Code)The Cmnaclora nd
Li-
Car.law coca Cot apply m an owns of propmy sola builds ru improve thereon,and
who contracts for such pmjate with a contnmar(q licensed puuuenOo Ne Cenlrecbra \
KlaKtw w.
cxemp uneer5«. .B k PC for rhisseuon
(hurler - Dai
OR 'S COMPENSATION DECLARATI0
1 anal wa!<rm unser penalty pcpuryone0 thefollowingworureiom:
Ihave andwill for by maintaincertificate7of Co,Labor ode,fomfm WmkmmoC of the
sCompen-
whorl,as provided for by Section 3]00 of Ne Labor Code,for the perfomunce of the
work forwhich this pcmdi is rx'
[31 havew e and will maintain WOlperfor ante o the w Insurance.h mqui�by Section
My Wrathetabor Code,for themaroncam oathswork for which this pcnmil is issued.
Carrier:
Compensation Inwrancs aurin and Policy number are:
Censer: Policy NO:
CERTIFlC EXEMPTION FROM WORKERS
COMPENSATION
( is stinnnd not be completed tithe Permit is forohodde (510)
mkw.)
�^
D
I«oily Net in Ne perfonmuwe MNe work far which Nispcmdt is iuued.I shall
not employ any person in my manner m as to become xubj«I m I1t
the Wurken'Compen- MAR
R 0 O 2000
xmon awaof Cdifomia Dam 11R V
Applwant
NOTICE TO APPLICANT:If.arm,making this Ceni icau of Exemption,you should
become subjmt to the Wmtcra Compensation gormorm of Ne labor Code.you must
forthwith comply with such provisims or this pemnit shall be dmmnd revoked. By
CONSTRUCTION LENDING AGENCY
I hereby affirm this there la a cunswNon I.Ming agency for the peformarce.f
r ^
ft work
for which this permit is iwled(S«.3097.Co.C.)
Lenders Name
la rx Address
W I cansfy don,1 have read this appbmjiCh and mare But the,shove information is
C. QCOMM 1 agree to comply wit AI city caty rd Country ordinances and state laws relating m
Z building construction.and hereby autlwri«repre entanvC,of"I City to enter upon Ne
U abovememimcd property for impewtien purports.
Ia. F. (We)agree to save,indemnify and keep hamllcu the Chy of Cupertino almost -
C V ria ilima.jmlgmne.,ouu and expenses which may in any way acctuc Maur said City
>. W in comequme.M Ne'Coning of this pnmit.
(•+ �+ API .ICAN'r UNDERS NILS AND WI .COMPLY WII'D ALL NON-P01 N'I'
UZ SOI ,.R.'UI;Ti NS.
Sig t sof AppIiCmuConwam / D
HAZARDOUS MATERIALS DISCLOSURE -
WillNeepplicant«fumreWilding«cupmismrtdhanrdlchawdwameteriel Re-roofs
ax defined by the Cupertino Municipal CWC,Chapter 9.12.and the Health strand Safety T e Of Roof
Cod,S«6.23532(0] � YP
❑Yes
well a applicant or future imidng«cupurtuse equipmentordeviceswhich
All roofs shall be inspected prior to any roofing, material being
emit h.rmurx a if cpnlamlmnta as defined by the Bay Arca AG Quality Mmagetnent installed. If a roof is Installed without first obtaining an inspection
District? I a ree to remove all new materials for inspection. Applicant
❑Yes f1A)
m.mnala nquimnenu under Chapter 695 of the Celi un er$tands and will comply with all non point source regulations.
Ihave mad the hara•ddr
mu HTIN&Safny Code.Satimu 25505,23377 cad 23534.I understand Nal if
h ern corm at a th mY rcapnmibilitymndif Neaapml
n�uauNonz 'gem x iswa«e ofeCmihc %,L up« �a
0/� Signat re o Applicant Date
All roof coverings to be Class"B"or better
OFFICE