00030085 ,r CUPERTINO
Y _(
Oct 1.DIN f.DIVISION PERMIT CONTRACTOR,INFORIGIATION:
000
3Roo 1-r
"
DINGADDR!-SS: �� �J/� /_ 'Y II J
rte✓ //l{J�(�/�.�/ ;0--rSANITARY NO. APPLICATION SUBMITTAL DAT
OWNP NAME:
A � / U �� '�• ��'[� NIC CONTROLM
a
tCHITEL/ENGINEER HOLDING PERMIT INTO
QOw //w
r i LICENSEDCONTRACTOR'S DECLARATION ,(/I/j/O� � Job Description
0 I hereby.Rrm that I em liansw undo ryvvisions of Chapur 9(commcming �C.C,-L
F v_�Fw wish Seo force
affe, )of Ne BusitwsuM Pmfeuions Gale,WmYlicrnxis
<x f J in full fmtt and effect.G/�3 �yw /�•
19 Littnu Lic.N G
H O 5 Date— �Hj, CS DECLARA O
1 understand my plans awl W used u wMic records y/?
as licmxd PmfexioaW
OWNFA BUR.DER DEIN Commerce.
om arc
<.'Y ON
1 hereby amnn Nal 1 1. exempt from oe Calocas Ys License Law fm the
F O following reason.(Section V31.5.Busircx aw Profcxsiom Cade;My city m caunay
which on irea a perrnil to cmwtPct,atac improve,demolish,on,repair my atmmax Sq. Ft. Floor Area Valuation
c. prior to its kor ane.,ore requires the applicant fa such permit m file.signedstatement �✓
Nal W is licensed pursuant to Ne provisiom of Ne Convactala Brenta Law(Cluprer 9 U
(wo mingwiNSmtion7")ofDivision3ofi BusineuandProfnsimACadr)m
Nat he i.exmpl therefrom and the basis far the ClaClawc.emptian.MAPN Number Occupancy violation of ZO / P Y TYPe
Section 7031.5 by any applicant for a permit subjects the applim
cant .civil Penalty of '.V e- L
not mora Nan I,.hundred dollars($500).
❑I,asawnerarNemapenr.armyempayee.wiNw.geaxtneiraakcampematian. Required Inspections
will do the work,and IN stroctum is rout imanded utolfemd for We(5a.7(F0,Budnas
and Profession"
Code:The Contractor's License Law does an,apply to an Owner of
property wWuil
bds or improves thereon,and who does such work himself he through
his own employers.provided Nal such impnaxments tae ant humor Or offered for
sale.If,howexr,the Wilding or improvement is sold within one year of completion,the
nen-Wider will boo the burden of proving Nat W did not Wild Or improve for pro-
pose of sae.).
1,so owner,of the propau,,Oen eaclusiuly counseling with licensed antrurors to
comedo Ne project(Sec.7000.Business end Paf inion.Core)TW Canoarora W. /
erns,law does can apply to an owner of properly who Wilds Or improver thereon,and
who concocts for such projau with a conmator(s)licensed turtwnt to the Contractor's A
Lttnu Law. J_/
❑lam Laemptunder Sa. .BRPCfor Nis won
Owner Date a
WORKER'S COMPENSATION DECLARATION
I hereby affirm ander penalty of perjury rose of the following dada aturow
❑I hrvc end will maintain aCeniOcme ofConxnuo xlGinmm for WorkedCOmpen-
don,as pmvidw for by Section 3700 of the Labor Code.far the perfomunee Of the
for which this'our is issued.
1 heve ends will maintain Worteri Com,roution Insurance,as sequked by Section
37 of the labor Cade.for the perfomume of Nc wok for which Nis pemiith iuuw.
My WorkeYyFtyetii p Inru e4 c d Policy _Zy.7,�,rg Lai
Comer. Policy NO: �re'S` TR—
CERTIFlCATE OF BKEMPr1I N FROM E KERS'Z,�
COMPENSATIONINSURANCE
(This station need no WcomDl<udniche pemut is fmone hundred ddtan(5100)
I,any that in the perfomonce of the work Wourne object
this fly,W is ixuw,l shall
rot employ of person in any manner rp es m became subject to Ne Woheri Compen- . 1
Appluard. of California.Data Iry 2000 I', III
Applicant � UII
NOTICE TO APPLICANT:If,atom making Nis provisions
o of Labe' ad you should II r MpR
Wcowithconpto Ne Workers Compensationproviriom of theoard Cad'.you mot
forthwith comply with such provision or this permir awl W dernRd revoked.
CONSTRUCTION LENDING AGENCY —
Q 0 kforw which
thi than Nem isecon(St..3n lending agency for the perfumwtce of C'N
Z du work for whicM1 Nis pemut is issued(Sec.J09].Civ.C.)
atamer's N...E Zandermer's Address
A. I certify than 1 have reed duo application and tame that Ne above ors relating to
Gr 0 builds.l.gra to c comply with all city end counts ord fives of and cmc hors r upon t to
D Z aWi ingconawction,and hcmby auatoriureresel. ion of this city to enter upon the
C.) .hove(We)s nc 1.sartc far courly an puryaus.
Gra (w)
(We)since to xve,indemnifyandkap ha,in anthe City d Cupertino said
City V incoistrict of ON
and e.peme.wMch may in any way accrue aganxr said Ciry
>+ W ineonse ANT ol)r.gmnungaf this permit.
M- APPLICANT UNDERSTANUSANI3 WILLCOMVLY N'I'rH AL1.NONdroINI'
f..) z SOURCE REGULATIONS.
Signature of Applican lConconor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupanwmc or handle haurelous materiel Re-roofs
as defined by IN Cupenina Mati al Cade.@apart 9.12,and the Health and Safety Type Of Roof
cax,s r]Yes YP
❑Yea No
WWII the epPlicanlo fmuu Wilding mcupanl use equipmem or devices whish All roofs shall be inspected prior to any roofing material being
cmithasstdousairconu2=1hoss
deflnwbylWB.'ArerAk(halltyMm.'rearl Inst` e . If a roof is Installed without first obtaining an inspection
°soak" I a e t remove all new materials for inspection. Applicant
❑Yea
"eye"" Ne h. . a . ai. un st ds and will comply with all non point source regulations.
regaretnenandtorose Heath 8e Saety C 2550$,is On,ard 25530.I u torify O Net if oe
building does mlcmently hevcamrtant.thpt it is my mapomibiliryunorifY�mcuparit ��" ��L-4—CDO
of the xgaurmeata which court be and prim to issueae ref.Cmificate of Occupancy,
ignature of Applicant Dale
Dwnu or authorised agent
Data
All roof coverings to be Class"B"or better
OFFICE