00030027 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 00 jJ 3 bb 3
BUILD/I7NGry ADDRESS: /'�
/V / �y / �M I A C C ///���✓/fn P/��/j/ SANITARY NO. —1—APPLICATIONSgU(BlM`nT^A'L DAT
E S ME: ��t�(jlnn XY/ 4/l O V A/ [^i/1/f rY • ') ONT `�V
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ARClll'F TIENGINEER +�Q 3-6 3 73 4 �3° 60 BULDINO PERMIT INFO
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"-zLICENSED CONIRACIOR'S DECLARATION
Z8Z= E I hereby alum Nat I turn limnend under provisions of Chapter 9(com ucceing Job Description
I -J wiNSIXtioandIofDivisimJofthe BYsitteOWROfeviwn Code.WmY license is O L,)
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<y in NII forte W eR L 1�tt Z O 0 T/ '^�/ ••f(/VIJL_�!l/
n'' IieeN ee Lic.X
W.•3LLU Data.t.�Coo VOebr ATIO -4 . -e 1, I/(y
e O 1undemandra plan Neill�beLuu4 tEpublic rcr s �.�(� -LA
w / ^'s'N+✓l
d LL e
Licensed Professional
OatNEm .a.DER DECLARATION
1 hereby,(Sact Net 1 roe exempt from Ns CttucerCo s:My c Law,(m the
f�o followin8 reason.(SIXtit'ro31.3.Business and�ions Code:MY city m mumy
a—m which"Unrea a permit to cutmtenck aber,improve,demtliN,or repair any sommurt
prior to 16 isswer e,also"nircs Ne Wheaten for Nell famous w file.Signed sustained Sy. Ft. Floor Area //,,�� Valuation
Out he is littted pursuant to Ne,provisions of the ContsanWs Lira se Law(Chapse9 60 "T v n
mtmmeemg with SIXtie.7(Xty.f Division3ofOa Bud—••and Professi...Cods)m " 'umber, Occupancy Type
f.he i,Excmpl therefrom rod rite basis far Ne Waited e.emptimr.Any violation ef ^ 194
P Y YP
Section 7031.3 by any Applicant for a permit subject[the applicmzto a civil Petty of �.
pof more Nen Eve hundred dollars WWI.
I,a.twnertrtheproprrtr.marempeyee.withwage[utheirAulemaprmmwn. Rck uired Inspections
will Bothe work,end the ewnum is not in¢nded or oRerd for selc(SIX.
7014.Business
and professiom Code:The Contsacmr's License law Owes not apply to an owner of
property who builds or,impmves thereon,rope who deem such work himself or through
ME own employees,Provided Net such improvements are rot intended or offered for
isle.IL however the building Or improvement is sold within one yeanofccmplauon,thr,
rbuildm will have ft burden of proving Net he did not build or improve fee per-
you
I,sa twee of ct property.as Sinus soul conveting with&Coadonnnsumn U.per-
construct the,project pply . n,wneirof rope Prowsvot Code)The Convectors lis. w
anise raw does et apply m an ower or property who builds or improve Nercunand
whoconvacts for such pm*.with a contrumdOlkenudnuan
put w the Conbumts
License law.
❑I am carolsunder Sec. .B&P C for Ni[ocean
Owner Da¢
WORKER'S COMPENSATION DECLARATION
therebyn ore underpmet,cefperjury one.1 0.following declarstiot:
I]Ihevc ercbs.'timm�e RrtiOweof Cotes moll-inurcforwokds Comprm
cation,as Provided for by Section 3700 of the labor Code.for the performance of the
work for which this permit is issues.
II have end will nuimsin Worksfs Computation Ivsunnce,as required by Section
3 0of dm labor Code,for Or,performance of the wank for which this permit is issued.
My Worksey�a�oto carries rod Policy
Coni¢ V/ter f�Pohcy No: � O—
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisyeti—need nm ba mot,l.ed dins permit is fortehundmil fullers($100)
or Ices.)
I cenify Out in the performance of the wmk for which this permit is issued,I shall
not employ my person in my manner so as to become.abject to the Workeri Compen-
sation law.of California.Date EMA
Applicant ILNOTICE TO APPLICANT:If,aft.making Ni.Care ficate of E.empion,you sbould Dbecme mbjetm Ua Wori Compensation provisions of Ne lesions Code.you mustforthwith comply with such provisions ons this Permit shall M demand revoked. 2 2000CONSTRUCTION LENDING AGENCY
0I hereby Afirm NU there is a conumebon leading agency forthe prformm<of
Z the wmk fa which this permit is Issued(Sc.3097.Civ.CJ Lenders Name lander'[Addres -
ry) I cenify that I have rad this application and state Nat the above Informnit is
dcovert.I agree to comply with dl ciy and county Ordinances and stem
laws dating to
O Zbuilding mmmoredon.and herebyamhoriu repeunmive of this cityto enter upon the
V O mos-ormaioned p,mtY for imepucuon purposes.
It, F- (We)agree N save,indemnify and keep harmless the City of Cupertino against
O O li labtics,jndgments,cans East expenses which may in my way Emma against said City
} W Immitsm.cnce of den grand,MOO,prrmit.
F C, APPLICANT UNDERSTANDS AND WILI,COMPLY WITH AL1.
V
NON-POINr
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slgtrnreanvvba ocmr
/ I / 0/ltlCCiat (lll// /)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hanme hazardous materia] Re-roofs
as defined by the Cupertino Municlp d Code.CT.pmr 9.12,and the Health and Safety a Of ROOF
Cade,Section 255321a17 Type
C]Yes ONO
Will the applicant or turn.Wilding ecupmt use msiipmem or device.which All roofs shall be inspected prior to any roofing material being
mit hn�rdoua air consummate.u dcfl.W by the Bay Ara AE Quality Matgemem installed. If a roof is installed without first obtaining an inspection
inti.' I a ree to remove all new materials for inspection. Applicant
❑Ye E]No
(have rad the ha7udoualttmala requiremenn under Chapter b.93 of lk Cali un ersta d and will comply with all non point source regulations.
forms Health&Safety Cade.Sectiaa 25505:23533 and 7553x.1 undersand that if the
building does na,trandy have x unml than it is my respomibiliy to notify Nn oem art �� 3 Z
of Ne mquirmmus which tun be,mm prior to ianumce of a Certificate of Ottupeey.
Signature of A plicant Date
(owner m Emhodzed,gem Data
All roof coverings to be Class"B"or better '
OFFICE