00040047 fNIC
ITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR�INFORMATION: �O"o
DINGADDRPSS: /�
` <L te n�k`J �J dir0 (� (.4L�ll G 7 / I L-• SANITARYNO. AP�ATIONSU�LDAT
IiR'S NAM(;: 'Y l I Peek / 1VI CONTROL#
i 9SL2� D
7O �- 1 a HOLDING PERMIT INFO
nRCECT/E [�]NEER fV� ,La Li��'. / Z 7� V
u o Z 6 /Jj, ,-�II
F.m_
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7^ LICENSED CONTRACTOR'S DECLARATION
ZO i=? I hereby affirm than 1 am licensed under provisions of Chapter 9(commencing Job Description
FSectimlgp)o(Divisian3aftM Bmincnand Profmaianaeode,and
force endll force end eR , ✓�
rL p m raj lieenaI Clan Lic.g j' D � �',...
3 LL G Date cono-ECI-
t1 understand my plans shall la,used as public iaads
no reo OV,ry
Liccnmd Pmlcuiorul
uK1
OWNER-BUR-DER DECLARATION
1 hereby.(Sera onn 1 am.Biu exempt from the Comramets Licence taw for the
F G following reams.(Section t ]rear S.Businns and improve.
coiom Cude:Any city a county
C ire. its rum a pemsio to cumwc4 alter,improve. perm N,fi rtpev any s itoom e
Sq. Ft. Floor Area ^� Valuation
pnonodsiaousneq ultopic.,
twieMvisiocanff Conpemdtmfleasi w(Cmptenf ,L co
Wtheislicensed Swtonto N)provisions 3Jan eButi ofs Lieensetaw(Cl )9
(cat he
ingwithher fimnandthebasisan3 ofaleged easeMAny vi Cade)or APN Nu ber Occu ane Type
that he i,exempt therefrom and for beers for the alleged the exemption.t Any violation of 1 P Y YP
nor on 7031.3 by hundred
apd doll for•permit subjects the applicant m a civil pwlry of
'�— a- Oc,
eta more Nen five hundred dolor,y employees p
❑Lea o work.Jan property.m ter ntendwith w.ges u weiSes.compenaniess Requ irefl Inspections
.IIIdo
etwon,and the shaaureisclots Uum",or.1fimul dolor We(See.]oat,Ownera
end ertye hm ru Code:The Canvxtois Cumin Taw does owl apply s lf owner of
his mv.who build,or improves Merton,and veno docs ench ware himself ar Jed for
his own eaw ver.t e provided thin such improveaid w thin not intended a offered for
We.If.Imwevar.the building ur en of penvine is roll within rare renalwmple Tory the F 1 N A LE D
owner-Wilder will have Inc burden of proving that he aid net build or improve for pur-
pouo(We).
c I, i owner of Jan property,,m exclusively conmaating Code:)
Thand conaaure- - 7 ^O O1
croswa pee project(Sec.]ai,wrier
rope Professions Code:1 The Cax dam
mr4 end MAY 17 L
cense law dee nm apply to an owner of propertymaters who builds or improves thcrwn,end
who contracts for such pmjeeu with a contracmrfal licensed Wnuant m the Canummrs
Licanm law.
Acerae-aw. nndergee. .B&PC far thi,rtman BUILDING
Owner Dole
WORKER'S COMPENSATION DECLARATION
I hereby alfrn under penally of perjury one of the following declinations:
IbveandwdInumuin•CmifweorCon rel so self-insurtforwokcreCompen-
alion,as provided for by Seeder 3700 of the Labra Cade,fa the pc*--of due
work(or which this permit is issued.
1 have and will maintain Wcrkefa Compensation Imunnce.as required by Station
3700afthclabur Cod for peAarmmce ofthe work forwhichthis permit is issued.
MTr. Y ejn�poand No.:
9'bD776�
CERTIFICATE OF PfION FROM WORKERS'
COMPENSATION INSURANCE
(This sectim need riot becanplemdifthe permit is form ahundrcd dollen(5100)
o less.)
I terrify that in the performance ofthe wwk for which this permit is issued,)shall
out employ any fiction in my mmm,an as no Wcome subject to the,Workers Compen-
W inn taw,of California.Due U72000 ApplicantNOTICE TO APPLICANT:If,after meting Nis Cenifcate of Exemption.you should
become subject ro dm workds Compensation provisions of the labra Code.you mustforthwith comply with such provisions m Nis permiulWl W deemed«yoked.OCONSTRUCTION LENDING AGENCYI hereby a(fnm lhn them is a comrocfim lending agency for the perform..of Z the work for which thio porn u issued(See.309],Civ.Q
Leedeex Name
7 lander,Address
I ttnlfy that I have read this application and,rare that the above information Is9L correct.)agree to comply with ell city and sway ordinances and num laws misting to
p z building coruwcdon,and hereby authorize mpremmativer of this city in enter upon the "
U 0 above-mentioned property for inspection purposes,
fa, F tWe) •res m save,indemnity and keep hamlOth
r , e City o(Cui mino against
t„) limilities.j ma.c uandexpenseswhi naymy way accrue against said City
;ae Ltirncon'c" of ing of this
F
III
APPLICAN' UN i .\NDSA )W NIPLY\ LL NON-111INT
V SOURCE R C A S.
S' caruCo in Date
HAZ USMATERIAI DLCLOSURE
III the applicant or for=Wilding occupam acme m Inmate hsasndous mderial Re-roofs
as d in by the Cupertino Municipal Code,Chapter 9.12,and the HOW ami Safety Type of Roof
C :Sectim15532(07 YP
,Yes ON.
Will the applicant Or future building occupant use equipment or devices which All ro fs shall be inspected prior to any roofing material being•
not hoodoos av contamirunu as defined by Ne Bay Arca Air Quit Managenram install d. If a roof is installed without first obtaining an inspection
p t' I a re to
0 ON. move all a materials for inspection. Applicant
Ys
I <mad due dote memo a rimount,under Chapter 693 of the Cali- un e , an it p ith all non point source regulations.
forms He ling,Sode. 'ora .25533 and 2553a.l understand that it the
building tI alen t bismyre nsibilirymnaifY Joe mcupant N '/��r/�lJVa
I its fec`ddwl( nf47.uppgp y_M Si tu-r_eoF'___j eant Date
Ow oreuNon,ad,orl I Dam
All roof coverings to be Class`B"or better
OFFICE