00030094 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTORINFORMATION: Jg
BUILDING
ADDRESS
/S•/L�Y�KC2_T1I'����lI�l[2GI��O I�� (1aCJ OO CaO5�// 0 � SANITARYNO. APPLICATION SUBMITTAL DATE
OWNER PC4NIC CONTROLp
PHON;: qD ❑
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ARCHI'T'ECT/ENGINEER ��� ���` per—/��
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BULDING PERMIT INFO _
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LICENSED CONTRACTOR'S DECLARATION
C 1hereby t700)of Nato 3livened uMcrprovision of Chapter commencing Job Description
iswith Seationual IT fDivision3ofdre Busimrsand Pyofcxrio tle, tiny littnm is
=yro.�¢ in bell force aril cR<n. /
OwU Limnec Clary Lic.g
Dau Convenor �,^'Af,L/j , , •Vy
five-a O g ARCHITECTS DEC
i rs my plow shall be used es Public records
`z�a0
w$pil❑O Licensed Profe..und
c OWNER-BUILDER DECLARATION
C z I hemhy affirm thin 1 am nempt from the Conlrasm',License Law for the
0 following r<aan.(Sectioo 7031.5.Bnirsas n d Prnrwiom Cad,:Any city or county
uu—m which rNuira a permit to corvvucl,eller,impm,e.dem.ITW,m repa'v any svucmre
3_ priomneal
rmitsixa , rorequthc
iresapplicantforsuchpemdttofile.sipRdwmment Sq. Ft. Floor Area Valuation
that he is licensed pumuam to the provisions of the Con scrota License Law(Chapter9
(commencing with Section 7000).f Dwki.nSof the B.6neas and PiMmmona Cods)or APN Nw bar Occupancye
tint he is esempt therefrom and the breis five 1M alleged exemption.Any violan of .xy z g TYP
Section 7071.5 by any applicant fa a permit mbjecu the applicant m e civil puulry of )o p
not more Nen five hundred dollars(351101
D 1.tie.worm of th<pr.any.or my employees with wegaa m their sola<ompemeti.n. Required Inspections
will do Ne work,and theawnum is no imrndndor.ffemd for Me Rec.7004.Bun
uns
and Professions Code:The Convector's License law does not apply to an mwmr of
property who builds or improves thereon,and who door such work himself or through
his own employer"provided thn such improvrmcnu art nil imerded or offered for
sale.it,however,the building or impmvcmenl is Bald within.ce yearof complelian.the
wm'-wildcr will hrvc N,border of proving that M did our Wild or impro c for par-
pott of tile .
I,a ow r of dm proany,am eacluriv<ly convssiins with )The d convectors i. /
emm a the project(Sec.o an owB.ner
of and property
who Wi Code:)The Convector,a LF
who come doss not apply to an with
a of proper(vela Wilda or improve themCorron.si ansi
es
who contracts(o such ptajecm with econRutorfsl licenced pursuant m the Contracmra
Licenselaw.
E] /1 am exempt under Sec. .B de P C for Nis reason
Owner Dna Q
WORKER'S COMPENSATION DECLARATION
1 M1cacby affirm undn Cavity ne perjury conent or ale folloe Ro dccHres Co
st I havr and will for by
eCion 37M of Corvnn loCode.for the Wmkera ce pen-
of the
mrion.as provided for by Section l]00 of the tabor,Code,for the performance of Nc
V"forwhich this permit is issued.
have and will mein tin Worters Compensation Insurance.u mourned by Section
SSS]00or Nc labor Code,for the prrformaott of dr,work for which this perm.is issued.
My Workers t Iqs, ,earn.and Policy wNed¢ra PY.�!
Camec�tt-AA Policy No.:FrH—I� 1T!
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This ration need not becomplemE if Ns Knot is fmone ImundrW doll»(SIDD)
or lcsa)
1 comfy that in the arfomurmr of the.,it fm whilh thio permit is ismad.I thall
not employ any anon in any manner so in to become subject to the Warkere'Coman-
salio i Laws of Califomie.Date
Applicant
NOTICE TO APPLICANT.If.after making this Cmtifmcete of Exemption.you should
become mbjecm m the Workers Compensation provisions of the Iauor Code,you most
foMwith comply with such provisions or this pumit rball be darn d mvAM
CONSTRUCTION LENDING AGENCY
p I hereby aBirm Out them is n commotion lcndingagency for tweeof
the perfun
Z LDthe work for which Nis permit is issued(Sec.3(97,Ci,C.)
Lenders Name
lenders Adding.
WI certify that 1 have read Nin upplici tion and Bute that the aWve information is
0. A correct 1 agree to comply with NI city and county odinenmc<s and sum laws relating to
U Q building convection,amt Inmby authorize rtpresenwivn of this city m enter upon the
above-mentioned property for impaction Puryous.
ts, P (We)agree to use,indemnify end keep hormion the City of Cinaso.-gaunt
Q V Iubilitiat,judgmema,cow nd rxprnrnr which may in any wry aecrve.,nian said City
} fir] in corse verse of de grunting of alis permit
f^ a API' C. f NUL SV'r NDS AND WII.1.COMPLY W l'I I ALL.N(jN-P0IN'
Zi 501 lC L 1 UNS. r
z !c 3�1�1/llt�
Sigmmm of ApplicanVC.ntfDO
HAZARDOUS MATERIALS DISCLOSURE I Utah,
Willthe applicant ydit,C,ritin inure Wildinge.Chartlmmor handle Heaous lth and Sdcly Re-rOOfti
u delimedSaa i tbe Cupertino Muracipsl Code.Chapter 9.12,and the Hcilth and Safety Type of Roof
c.an,secaan ssvz1.17 _/ YP
DYat t�
Will the epplicam or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
rut;,heaadous air conmminmta ac Burd by the Bay Arca Air Quality Manegamem installed. If a roof is Installed without first obtaining an inspection
°I"^`" I a tee o ve all new materials for inspection. Applicant
D Y<a
0%0 I have mad the hamrdoat material.rt,imsrcomarder Clap 6.95 ofdc Cdi. un ers and d- ill comply with all non points tee regulations.
fond Ith re Cade, tion 15505.35533 and 35530.I understand Net if Ne
huilain das u ly he��s}}55aecmnam,thn it is my mponaibilirym miry Nql� pmt '
of
Nc ahmgslFa me�prior to issuance ofa Ccpf ycybyy�.
==11==11/r�a�� Ir7�(f(J Signa[ureof pplicant Date
owns r e n Pn you
All roof coverings to be Class"B"or better
OFFICE