00040094 CITY OF CUPERTINO - PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 0,00Y00 -3 Ll
BUILIIINGADDRESS:
5ANIT'ARYNO. AI'1'LICATIONSUBMITTALDATE
/07ak7—
O NER'S NAME: ti�JL NIC CONTROL#
I�Awey �au�nc� 17
AARCHITECI'IENGINEER w(-C- _ /J 9lILDINC PERhtI"f INFO
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LICENSEDCONIRACfOR'SDECLARATION
z o y— 1 bMOy drum Nat I w liccnud under provisions of Chapter 9(cm ming Job Description
OZZ_.4w�{ wiNSavion]000)ofDivision3of Ne Buximuvd Pofeuiom Cate.WmYliuveis
M.na in full foCiemd eRml. _ f
O w U Have Clea Lion,M �G&T,�"/�, GZ
a�3 LL DaIC ToS DELL
F LL C e, ARCHfIECTS DECLARATION
f w�• I u ulimmnd my plans shall W usual u public records
Licensed Prokaional
dar I.BUBAER DECLARATION
{=Z 6 1 herby aRrm on 1 am evempt from On CoovactC's License law co Ne
to is po following rtas;a(Scalia meson t.Oct. ad Re.derona Cade:Any Mity orouuy
to'z m fammmgrims.permit incrarucbalter.improve,dpermit me a signed
ig ed statement
Sq. F[. Floor Area Valuation
pdmmslicenencealwmgo the thovisio antsof rte such permit icams,g�mmmem O v
Net he is licensed punuam to the provisions of the Conrtvcto/e Licenu law(Chvper 9
(caamcamng with sedam]000)ar Dlviaion3rr Ne Brained ma Proreaimu coddw APN Number ccupancy Type
Wt he is eKmpt thorefrrm W da basis for the alleged reconfirm, Aay violation of / /
Sation]031.5 by any spplicenl for a pernJl wbN
jmts e applicanuo a civil penury of (.7 /G— 0-22 S CAiG._
tat mom Nen five hundred dollars(S300).
p Required Inspections
will dofa work,ede: heC.cisnot inmdedo Law
to.Bualnns
and Profession Cod.:M Conuactrem Li«rue law alas iwt apply to lf rwar of
his w.wW Wilds fu aided O thereon,sod who alas Wish work deed-m drouBh
his own however
de pmvldd Nat arch improvements bi not inmdd w odemd for
We.If.howev will Wildingnorsteam I.soldwithin act man
rr improve fee
7
owner-Wilder will lave IW burden of proving Nel W did soh Wild m improve fm par-
KL
�Q
of ate.).
ins—
owrcr or do,pmpeny,am aclualvmly comuuung with Horned rontrxton to
wet Ne project(Sec.70M,Business ad Profeaion Code:)The Conuacene.Ii- l0
carr Law does Win apply to m owner of property who Wilds ampr
turnover;thereon,and O
wW comaechs For such mi..with a ronaaclar(d hcrmd pursuant to me cimormwts
Lic u
❑lames rpt under Sec. .B&P C for this recon
owner Dam —
WO I iR' CO ENSATION DELLA TION
IWmbYeRrm der Pendry of p.rjury oa of Ne follaadnB dmlantioa:
]I have ndwillrminWna Cenifc=IsolConsenuoselGinmmfwWmkchCompen-
ma,as novied for by Safion 3700 of Ne Labor Code,for the performance of the
wk for which this permit is issued.
El 1 have and will maintain Workci s Compensation Insurance.a requited by Sahirn
37M.f de LAW,Code.fm the performance of Nc work for which this permit is issue.
My Wnrka's Compenution Insurance cams ars,Policy numM am:
Cenier Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section rand not be completed if Ne permit is forma hundred dollars($LW)
or las.)
I cenify,dot in Ne performance or Ne work for which Nis perouh is iaued,I shut
not mploy any person in any manner so as to Wcome subject o the work=s'Compen-
sation law=of California,Due
Applicant
NOTICE TO APPLICANT:if,after amusing this Certificate of premium.you should
Mame subject to the Wohefs Compensation provisions of Nm Labor Code.You mal
forthwith comply wit such provisions in this permit shall be dated svokd.
CONSTRUCTION LENDING AGENCY
Q Q I Wreby dfirm NU mare is•construction lending agency for the perfmr 4
Z H On work for which Nis pelmil is issued(Sec.3097,Civ.C.)
Inde/=Name
a 7 I.d,e,Addmas
(� 1 cenify Net 1 have read this upploa ion and stem Net Ne vWsc ii fomutiou is
L correct.I=gree w comply with all city and county mlonarces and sum laws mladnB to
.�. Z building construction.Kid hereby authodu rtpreunmive=of this city to enter upon the
V C =bove-memioned property for matim in pmpici
Ln r- (We)agree wave.indemnify and keep Mmlea the City of Cupertino agent
0 V liabilities,jdinents,cam and expenses which may in any way accrue against said City
} L4 in con. 9umce of de gmming of Ods ren
[� d APPIJI Nf UNDERSTAND. 1) II.LCOMPLYWITHALLNONdVINT
V z hOUNC fREGULATRINS.
-/ -
.igtmm,.fApplic a ct ma O � A--ro/li 0G•
nA
H YARDOU MATERIALS DISCLOSURE
Will the app c for future Wilding oecupam shim or haute hsaadone rumored Re-roofs
in define by the Cupertino Municipal Code Chapter 9.12,and the HwN and Sarny Type Of Roof
Code,Section 2553200] yP
0Yes CIW_
Will Ne applicant or future Wilding mccupmt use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit haaandoa air cumamirmna a defined by the Bay Arta Ab QWiry Management installed. If a roof is installed without first obtaining an inspection
I agree to remove all new materials for inspection. Applicant
Ys
hi Wve rsad Ne haardws matedah rryuimmenu under Chapter 6.93 of do Cali- Understands and will comply with all non point source regulations.
f -
catch&sal=ty C 25305.25533 and 25530.I urdmstaod Nm if the
buildm docsna curtmtl veer mit.Natih is my mpendbilirywmify0 thgeompmt
of ma uummus whic n ' r w as W is enceLf migce fff/
Signa1144 ture of Applicant Date
n, Be Date
All roof coverings to be Class"B"or better
OFFICE — ------ _