00030139 CITY OF CUPERTINOPERMrr NO.
BUILDING DIVISION PERMIT CONTRACTOWINFORMATIONs.,.' 0p 030J 3
R
IN ADDRESS �ga( - //fISANITARY NO. APPLICAT ))�N SU�jBM AL DATE
^, Z NIC CONTROLN
ARCHI"rECTIENGINEER - BUILDING PERMI'rINFO _#
on z
00
u
z
y5 .
H N z LICENSED CONTRACTOR'S DECLARATION
o a=0 1 ion 0 affirm Net I thn fTBu undo prorlswns of sCode. 9(commencing lob Description f
r,__w wiNS«tion 7000)afDivision3ofCoBusincss and Rofessions Cade.sea my lianm is � �� �� /�
yd2 in full form and effect. �V
14
u O d O Lionu Class Lic.N
3 y Dau Convacwr
C LL O¢ ARCHITECTS DECLARATION
u�y, 1 understand my plans shat be used u public«cads
c'�00
a.S �c ticensad professional
nS R N OWNER exempt fr m the CoATION
1 hcrcby eRrm Net 1 am exempt from Co Conuacmrs Licanu Law for Co
' D following moon.(Section 703 1.5,BwNas and Profaiau Cade:MY city or munry
ui C$ which rrquit«a permit w co m cl.Wer.improve,demolish,Or main any smucmme
a3' priawitsissuance.asorcquiresCoapplicantfmsuchpemdtmnle.signedstamment Sq.Ft. Floor Area o Valuation
Npursuant at he is licensed pursuano the provisions of Ne Contractor's Uccnw Law(Chapter 9
(entrustment,with Seetion 7")of Division 3 ofNc Buri«u and Profusions Cose)m N u bar Occupancy T e
WI he is exempt Nertfrom and W buffs for the alcged exemption.Any violation of 2// 3 9t P Y YP
Section 7031.5 by any applicant for a permiuob rats she applicanto a civil Kindly of <P Z—
Qes more Nen five hundred dollars(5500).
Las owner ofCopmopeny.or my cmptq«s with wageso Coir ante compenatian. Required Inspections
will do Co larejesitim" nd el smucwm iuwt imcranse Law ed s war s iec.7014.Buser a
and property who Cak:The weiCom;th rve License law does war apply to M wm gh
hicam who W Side or improve t such i ea who does such words himself a through
his own employs,provided io wen dopa«menu thin nee intended a olraed for
aln.I[vileor will
Wilding or en of proving thus
sold within oneildori improve
Co
nbuilda will have Co Gorden of proving Nat rte did no build m improve fa per. _
pose tar ole.). /
I,in t due
of N<property,thn exclusively contrasting with:)TheW contractors U.
mwa d project(Smapply
o an ni of and Py femsionswho Wi Codei the Contarman.nd
cane Lawdosnotapplytots ownerorpropcny who builds or ant to the barman.and
who contracts for such prol«u with a mntractm(O licensed pursuant w the Contractors
License law.
1 an,exempt under 5«. .B&P C fa this mason
Owner Dat
WORRF.R'S COMPENSATION DECLARATION
1 h ml affirm under pandty or penury con of Co following d«Iwiore:
❑In.ve arta wm mamwn.Ceninrthe nrcaaMua eeff-ineamrmwarker.compen-
ration,as provided for by Section 37M of the Labor Codc.for the perfomunen of W
work for which Nis permit is issued.
❑1 have and will maintain Worgives Compenotion insurance.as required by Section
3700of Ne Labor Code,Or Ne perfortnaece of the work for which this permit is iswed.
My Wormrimmil Polity /
Put
icy FROM
CERTIFICATE OF COMPENSATION
N FROM WORKERS'
COMPENSATION INSURANCE
(Ibis s4aiaa ncedran beMmplelW ifCo pmwtisfaa«hundred dellen(5100)
or,less.)
IcenifY Natio the performerceof the workfor which this
permit ssuvLldWl
not emp10Y nt 9cfto tho kkcn'Compn-
uL-
ew
A,u,
NOTI PPLhe vvor:1f,atom making this provisions
n s o the
Exemption,you should
becor«suompy it Wmhero Coons.1 ix pmviasul of Ne Labor Code.you most
forthwith cmmPIY with such provisions tar Nis permit shell be demerit revoked. ,
CONSTRUCTION LENDING AGENCY
Q Q Ihereby affirm fort Nem isa comwcGon lending agency for Co'Kin once of
Z W work for which this permit a issued(Sec.3097.Civ.C.)
{K Lcndela Name} lenders AddmsF
WE 1 certify Wt I have reed this applio.a.and note that Ne above information is
0. correct.l agree to comply win,ell city va count)ordinances and state laws raeGng in
Z building construction,thin hereby mourner mprt«nmtiva of this city w enter upon the
l i udme-mentioned pmKny far inspection purposes.
(We)e,.on save.indemnify and keep hthmless the City of Cupertino agawl
Q C.1 iiebotics,jw)r«ms,consentleapenus which may in any way sccrve agann oitl City
} W in canoe, c of Ne gmnting of this parent.
(• L API 1 UNDERSTANDS AND NLLCOSIPLY WITII ALL NON-POINT
REGULATIONS. /
.OfO
ig waofAMlicanJcontmcmr Das AR 'PDl/
HAZARDOUS MATERIAIS RE. A�DISCLOSU
Will Co applicant or forum Wilding occupant start or handle haramdnm mauda k roofs
as defiled by the Cupi nino Municipal Cede,Chapter 9.12,and the Heath and Sauy Type Of ROOT
0
Cede, tion25532(x)7 � YP
Yes
Will Wapplicanto home Wiminguccupantuse equipmentordevices which
All roofs shall be inspected prior to any roofing material being
emit hssacdous air mrsamornams as defimrcd by the Bay Arta AG QOWty Management installed. If a roof is Installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
❑Yes
1 mad Nen.vaowonsmiaamquimmentamaerchapter6.95offorUi- un erstands and will comply with all non point source regulations.
&Saety Code,Serums 505,23533 and]5534.1 undentan d thu if the
as nee cmmntiy naveao tism sponsibiliry modify Cooavpant
nm which the p to i1 Of a�M� fry
ee^` �� Signature of Applicant Date
Ow er or euthomized agent Dam
All roof coverings to be Class"B"or better
OFFICE
CITY OF CUPERTINOPERMrr NO.
BUILDING DIVISION PERMIT CONTRACTOWINFORMATIONs.,.' 0p 030J 3
R
IN ADDRESS �ga( - //fISANITARY NO. APPLICAT ))�N SU�jBM AL DATE
^, Z NIC CONTROLN
ARCHI"rECTIENGINEER - BUILDING PERMI'rINFO _#
on z
00
u
z
y5 .
H N z LICENSED CONTRACTOR'S DECLARATION
o a=0 1 ion 0 affirm Net I thn fTBu undo prorlswns of sCode. 9(commencing lob Description f
r,__w wiNS«tion 7000)afDivision3ofCoBusincss and Rofessions Cade.sea my lianm is � �� �� /�
yd2 in full form and effect. �V
14
u O d O Lionu Class Lic.N
3 y Dau Convacwr
C LL O¢ ARCHITECTS DECLARATION
u�y, 1 understand my plans shat be used u public«cads
c'�00
a.S �c ticensad professional
nS R N OWNER exempt fr m the CoATION
1 hcrcby eRrm Net 1 am exempt from Co Conuacmrs Licanu Law for Co
' D following moon.(Section 703 1.5,BwNas and Profaiau Cade:MY city or munry
ui C$ which rrquit«a permit w co m cl.Wer.improve,demolish,Or main any smucmme
a3' priawitsissuance.asorcquiresCoapplicantfmsuchpemdtmnle.signedstamment Sq.Ft. Floor Area o Valuation
Npursuant at he is licensed pursuano the provisions of Ne Contractor's Uccnw Law(Chapter 9
(entrustment,with Seetion 7")of Division 3 ofNc Buri«u and Profusions Cose)m N u bar Occupancy T e
WI he is exempt Nertfrom and W buffs for the alcged exemption.Any violation of 2// 3 9t P Y YP
Section 7031.5 by any applicant for a permiuob rats she applicanto a civil Kindly of <P Z—
Qes more Nen five hundred dollars(5500).
Las owner ofCopmopeny.or my cmptq«s with wageso Coir ante compenatian. Required Inspections
will do Co larejesitim" nd el smucwm iuwt imcranse Law ed s war s iec.7014.Buser a
and property who Cak:The weiCom;th rve License law does war apply to M wm gh
hicam who W Side or improve t such i ea who does such words himself a through
his own employs,provided io wen dopa«menu thin nee intended a olraed for
aln.I[vileor will
Wilding or en of proving thus
sold within oneildori improve
Co
nbuilda will have Co Gorden of proving Nat rte did no build m improve fa per. _
pose tar ole.). /
I,in t due
of N<property,thn exclusively contrasting with:)TheW contractors U.
mwa d project(Smapply
o an ni of and Py femsionswho Wi Codei the Contarman.nd
cane Lawdosnotapplytots ownerorpropcny who builds or ant to the barman.and
who contracts for such prol«u with a mntractm(O licensed pursuant w the Contractors
License law.
1 an,exempt under 5«. .B&P C fa this mason
Owner Dat
WORRF.R'S COMPENSATION DECLARATION
1 h ml affirm under pandty or penury con of Co following d«Iwiore:
❑In.ve arta wm mamwn.Ceninrthe nrcaaMua eeff-ineamrmwarker.compen-
ration,as provided for by Section 37M of the Labor Codc.for the perfomunen of W
work for which Nis permit is issued.
❑1 have and will maintain Worgives Compenotion insurance.as required by Section
3700of Ne Labor Code,Or Ne perfortnaece of the work for which this permit is iswed.
My Wormrimmil Polity /
Put
icy FROM
CERTIFICATE OF COMPENSATION
N FROM WORKERS'
COMPENSATION INSURANCE
(Ibis s4aiaa ncedran beMmplelW ifCo pmwtisfaa«hundred dellen(5100)
or,less.)
IcenifY Natio the performerceof the workfor which this
permit ssuvLldWl
not emp10Y nt 9cfto tho kkcn'Compn-
uL-
ew
A,u,
NOTI PPLhe vvor:1f,atom making this provisions
n s o the
Exemption,you should
becor«suompy it Wmhero Coons.1 ix pmviasul of Ne Labor Code.you most
forthwith cmmPIY with such provisions tar Nis permit shell be demerit revoked. ,
CONSTRUCTION LENDING AGENCY
Q Q Ihereby affirm fort Nem isa comwcGon lending agency for Co'Kin once of
Z W work for which this permit a issued(Sec.3097.Civ.C.)
{K Lcndela Name} lenders AddmsF
WE 1 certify Wt I have reed this applio.a.and note that Ne above information is
0. correct.l agree to comply win,ell city va count)ordinances and state laws raeGng in
Z building construction,thin hereby mourner mprt«nmtiva of this city w enter upon the
l i udme-mentioned pmKny far inspection purposes.
(We)e,.on save.indemnify and keep hthmless the City of Cupertino agawl
Q C.1 iiebotics,jw)r«ms,consentleapenus which may in any way sccrve agann oitl City
} W in canoe, c of Ne gmnting of this parent.
(• L API 1 UNDERSTANDS AND NLLCOSIPLY WITII ALL NON-POINT
REGULATIONS. /
.OfO
ig waofAMlicanJcontmcmr Das AR 'PDl/
HAZARDOUS MATERIAIS RE. A�DISCLOSU
Will Co applicant or forum Wilding occupant start or handle haramdnm mauda k roofs
as defiled by the Cupi nino Municipal Cede,Chapter 9.12,and the Heath and Sauy Type Of ROOT
0
Cede, tion25532(x)7 � YP
Yes
Will Wapplicanto home Wiminguccupantuse equipmentordevices which
All roofs shall be inspected prior to any roofing material being
emit hssacdous air mrsamornams as defimrcd by the Bay Arta AG QOWty Management installed. If a roof is Installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
❑Yes
1 mad Nen.vaowonsmiaamquimmentamaerchapter6.95offorUi- un erstands and will comply with all non point source regulations.
&Saety Code,Serums 505,23533 and]5534.1 undentan d thu if the
as nee cmmntiy naveao tism sponsibiliry modify Cooavpant
nm which the p to i1 Of a�M� fry
ee^` �� Signature of Applicant Date
Ow er or euthomized agent Dam
All roof coverings to be Class"B"or better
OFFICE