01050148 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
ItUI1.UIN .AX xg ^ PEbt;; � ).las-0
�� /n
OW'NER'S NAS /`/�}y `/( APPLICA ON SUP ATC (''(`j/�
�PHONE: -/✓w'�j � � �/+ SANITARYNf CON71IMNO,
a eco 0 ARC.I II'I'IiC'I'/IiNGINHER: BUILDING PERMIT INFO
u_ LUG Ii1.ECT 11i hllict
1=1 I_-. 1_I
¢N
LICENSED COKnNACnderp uGC,e,ofLARATION Job De$Cllp I1
K.E c 1 heron Rnn that I um licensed under of Chapter 9(commencing p Z-p y a Provisions p g
r V.'c with ' tion](NNp of Division3ofthe Business,and Professions Code j dmylicenne
6y ' full bass and effect. � Qr�` /7
Xm0 c accuse Class Lia tr_
m 3 u r m Correll,
g ARCHITEL't'S UIiC1.ARAf1(IN
1 understand my plain shall be,used m public records ,//F'y{/q/rV',f//`/ _•
rya Y
S p p Liccn.md Prulaaional
xOWNER-13UILUi?N DIiCe RATION
W I hereby am Ibar I am oxcmpl Eon,the Cantrunn�e L¢ntt Use for the
(Selina 7031 5,13usine"and 11ofl ous Cod,Any oily,,,corny
fZ0
oluel, ape,mi, h I ' I'.I R ya aux
cePro 1 1 to,a,,Ic;oIn, M1pcmul1 II '6 d,m1anu 1
a. that lie is hornwid pinnarot ma prosimumot flao C 1 Lism,1 (CI pier 9 Sq. FL Floor Area Valuation
us removing with Secuon]mN))of Divismn 3,e the Btioness and I'mfe..ione Code)
or that he is exempt Ihcrefmm and the basis ler the alleged exemption,Any violation
of Seeion 7031.5 by any applicant fora permit.objects the applicant m a civil penalty
of notation,than Esu hundred dollar,0500). rJ� Occupancy Type
❑I.asowneroftbe pmpcnY,or myempinyees with wages as theirsole eompcnsadim.
ill do the work.and the tact tt intended or offered for sale(See.](nkat.
Business and Porilessions CN 'rhe Commotor s oiccuse Law does not apply to an Required Inspections
owner
through
tplt I property 1c wooIJWimproves
n thereon,lJf 'M1 h' k himself
or h his own provided thou n p et. not intended m
chervil for
If however,thebuilding pet 1 . Id thin y r
will have dh1 i.........1hat he JJ tb ldr
, i p pl'I )
I fII pr P t y t ranting 'tlicensed n t
,ul ' d iet(S ?(ad 'ss 1 nca ,n Codi e at,aLnw does m In an'wnof roprly won hlceanimprove,thereon,
ndwIomiumfor om,1 project,with u conwctor(s)licensed paramount
/
to the
Col worSeeks License
❑1 inn xempt under See. .14 k P C for this rtaxm
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
❑ I have and will mod sin a Certificate of Consent to self-insure for Workds
Compensation, ae provided tor by Section 771X1 of the Labor Code, for the
"I'lenmme nl'the work for which Ilii.Iwmmit i,issued.
0 I h,,e and will n rinmin Wodxr'x Campcnsadon In.urarse,it,rimed by so"t"m
3900 of Labor Code,for the perfnmr.ncc o1 the work ser which this permit is
fy w,in keterx'!Cm11n'1mmr,illlon Inwtancu ender amt policy number urs:
rricr.C�CI'eRl'II,CATION 01'IiS1iMy11 lso: �15(1-�S &2,--9
COMPENSATION INSURANCE
(This sxaion need new he completed dine permit is for one hundred dollars
(SIM)or less.)
I verify that in the performance of the work for which this permit is issued.I
shall not employ any person in any manner ,,..,it)Income subject to the W ken'
Compensation Lows of California.Date -
APPllcant
NOI'ICH I APPLICANT.If,all,r making lois Cenilicntcof P}emptlon,you should
be ou e"'Heel m the Worker',Cmnpcnnndon provisions el the Lahor Code,you mud
Q O furl ltwid.annply wllh inch Pnrvisions a this...rete shall he deomW revoked,
rr�iCONS IRUC'I ION 1ANDING AGENCY
C7 I hereby aftin o tharth..a is u coweam lion Icohn,agency for the reformnce
W 0the wad for which his permit is owed(lice.31197.Civ.C.)
0. Q Cender'e Name
.= z Lunda',Adcress
U Q 1 comity that I have read this application and state that the above information is
4 (•" correct.I agree 10 comply wise all city and county onlinances and state laws notating
Q C) :u NdidingcoSuction,and hereby authmin,representatives oftbis dry to enter upon
G.7 he aMwe.rnentioned pmNmy for inspection purgne..
(We).91.msave.indemnify and keep harmless the City of Cupertino against
N lixbililics,juJgmcnts,conePuk",
y way accrue against snitU z, City ins fic API .I nNT UNl§S ITH AL1. ',N�POIP IS\nCd by: Date
gmmt PP Ic Dal Re-roofs
HAZANS DISCLOSUR11
will roe applicantof Inmm nuuaimg iµYapaal dart nr hanele hewd".e mnmrial 'type of Roof .
asdel edby the 32m)?m Municipal Cndc.Chapter v.12,nnJ(lin Hcahh ane Satcly
Cralc.Section0Ye255321x1'.' 0 No
All roofs shall be inspected prior to any roofing material being installed.
Willtheapplicantnrfuturebuildingnecupantusayuipstatordevice,which If a roof is installed without first obtaining an inspection, 1 agree to remove
'` emit hamodoux air contaminant as defined by the any Area Air Quality Management
District? all new materials for inspection. Applicant understands and will comply with
0Yn ON. all non-point source regulations.
have mad the hazardous materials mptircment under Chapter 695 of the
Culilornin Health k Safcq Csslc,ti l9R+rn 355115.155?3 and]5531.1 under mnJ that
il'Il M1nilJingdoc>nn sncndyhaveulcnun1 thin it ismyrcgamsihil'ny m notify the
e1 to of the rcym atm Pk,r m Is.uunce 1 a Certificate of
`)e' 1LY Signature of Applicant Date
All roof coverings to be Class "B" or better
nwne aid sed agent Dat
OFFICE