00020052 CITY OFCUPERTINO - - " ' PERMIT NO.
BUILDING DIVISION PERMIT CONTRAAA�CTOR INFQRMAtION::
dU1LUING AUURFSS:&Flhilal&" / 1,{�A /T/�D �,.31J�//zT-J��-/p�/J
D t/U�T//�nc• +`�//4 /,`ten'/—{�4y"f'�)/J/4' SANITARY NO. APPLICATIONSUBMITfALDATE
O N A'S N ME: I7& NN�O�Wi /Me-
NIC CONTROLN
AskR3N )25-7-87,539 f/GUDrd /5 _17
❑
ARCHITECTIENGINEER CS/o)293 -20/2 '+:.." y„BGLUING HERMITINFO fi",rr!,iYr ,:,
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LICENSED CONTRACTOR'S DECLARATION
1 hneby amen Om 1 w deemed urda provisions of chapter 9(commencing Job Description
t-:u wiNSmion tOWlofDivision3oftlu Business and Rofmiwu Cade.and my lonot iz
a i th�R � /�/akp /Aaf?r lfll? o aewvll 4(11*116�1606
i In fullf CI lie.N
Convsear
I_LL O Q ARCHI'IF.CTS DECLARATION
' I understand mY Pians shall M tial n W61ic scads
>.o LicmrW Nofeaaiond
OWNER-BUILDER DECLARATION
C]� 1 hereby smmm that 1 ann cBempr from the Contractors License Law for the
�H o (ollowmg tusan.(Section 7031.5.Business and Profcaiom Code:Any city a county
which a3— Fri«t0 its ancperdmsiut rrerqauaiamWtbeaepJpaliccant foo m<,h permit rooErlcreepsaigr«andy surmammmuet
Sq.Ft.Floor Area Valuation
that he is licensed famm nt mthe provisions of the Contractors l.icena law(Chaptm9
(rot
IMI heis eaxgmwpiNNSecfrom anndd3one,owns for
r the Alleged aevasanndption.Any iavmioelrtidoen3of
r APN lumber Occupancy Type
Section 7031.5 DY my Wduuot
for a permit aubjecu IM applicant to a civil pculry of
at mom Own!a hurdred dollars y employees
will
of....of red prapeny,or my of mayec.with wages u their sideSec.contamination. Required Inspections
will do New«k,and the evucmreistori Lt.. ".doindicted f«ers m1l,..sm Bowness
and Rofeauoba Code:Tia improve,
d a o i Liana law does nw rPdy s lf r tiro of
progeny who Mild or videova Neeson,and who does such work himself of through
his own cmployaa,provide this,such impms sold w eR not inar of rr offered f«
ownersale .hawe,will h vette b rden of zemem is an he
noaymof completion,the ,
Fier. uile.) will have Nc Mmdrn of proving Not he did not Mild a improve for Pur-
pose asale.).
I,comment Ower of Ne property, B eadusively and cunusImmill Cod:)'steed cmtnce. to
ameathe project(See.THa,Business and Pmfasiout&.1 toIla C therema Li-
cepa law does out apply m m owner of progeny who builds or imaovm Hereon,cad
who convects for such pojecu with ecmvacmr(a)licensed pursuat to Ne Conaecmrs
Lab w.
la
0am ./1
I <xcmptundo Sec. .B&P C f«Niz reason \/
Own Dau
WORKER'S COMPENSATION DECLARATION
1 hereby amrm under prnaltY of P lay ore of Use following declarations:
Q 1 have sodwill vuinuin aCeniOcaa ofConmmuo selGinsum/«Workers Compcm
anon,m provided fer by Lactim 37M of Ne Labor Code,for the perfmma.older
«k t which Nib pmnit is issue,
w have and will maintain Womkers Compcnation Insurance,a required by Section
3Agof the Leer Code,for the performance of Nc work for which this permit is issued.
My Worirar'p CftmAett�hn�a� cemcr and Policy number are
Carrier: Policy Nu:
CERTIRCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hcomplead ifthe permit in foronchusWeddlan(3100)
or less.)
1 certify that in the performance of the work for which this permit is timed.I shall
Iwt emoy arso
piny pen in my manner so as to became eubjxt to the Workers'Compen-
ation laws of California.Date
Applicanr
NOTICE TO APPLICANT:If,after making din ConiOna of Esempuan,you should
become subject to the Worker.COmpemani m provisions of the tabor Code,you must
forthwith comply with such provisions or this permit shall M domed revoked.
CONSTRUCTION LENDING AGENCY
O O Ihereby Ali.this Nem is ac...wetian lending agency for the perfomence of
the work for which IN.pcmtit is issued(See.3097,Civ,C.)
Li nder'a Name
} lender's Address
k� 1 rent,dm d this have read application anal area Nthe e above information is
a. zcorrect.I agor to comply with At city and county oemancrs and sou laws Wants t0
D .Z building commucuon,and hereby suNodre mpreanusbas of this city to enar upon the
U abov.-mendomd property for inspection purposes.
(wet agm«a ave,indemnify and kap harmless Oa City of Cupenitro against
O C.7 liabilities,judgments.coma anal expenses which may in my way some against aid City
} !z: in conuqucnce of the gmmung of this permit.
APPLICANTDNDTI - NOSA 'U WILLCOMPLY WITH ALL NON POINT
V z SOURCEREGUL( S
Signature of ApplicmV.o seta D
n RDOUS MATERIALS DISCLOSURE
Will We aifli t«foorm Wilding occupant start or hurdle himinhus material Re-roofs
as defined by IM Cuperfino Municipal Code,Chapter 9.11,sod the HeAt and Safety T e of Roof
Code.Satins 255311a)? YP
❑yesCtiano
DyesWill ft epplicmtorfumy Wildingacupontoreequipmemcardeviceswhim All roofs shall be inspected prior to any roofing material being
I
instant.AirIm mitunu as dcfmrd by the Bay Asa A.Quality Management installed. If a roof is Installed without first obtaining an inspection
note? Ole,
agree to remove all new materials for inspection. Applicant
❑Yes
Ihave mud Ota hared«n maadals agciremnmu under Chapter 6.95 of ft Cali- understands and will co with all non point source regulations.
tomo Health&Safety Cade.Sourness 25505.]5533 sed 255M.I understand that if the
huilding docs nm currently hie.Enol IMI it is in,asponsibilay m ewtify the acupat Z
of the rcyvircmeno whichmu t be urn nvt3nunce of a Cmiticate Or cape y.
2 I up Signature of Applica Date
Owner or authorized argent D
II roof coverings to be Class"B"or better
OFFICE