00020166 ctRoOF
1DIN mviROrvNO CONTRACTO,R',INFORMATION:` PERMrNO,
PERMIT 0002- 0 / 496
}I UII.DINCaADDRESS: ./'� /_ 61VAj� AW, I, */W.
1///v/{vy'/Y I/!/✓/ �E/ �c C• SANITARY NO. APPLICATION SUBMITTAL DATE
1&4d�q 6114,f �� lZl AM w, N/G CONTROL#
0 7- �(� Nl j/U/0�d, �i940 9y5yS//-/X22 ❑
ARCHITI?Cr/[iNGINEER fi)d -��� ^20/G DULDINCPERh11T INFO. ;f`_"
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LICENSED CONiRACTOR dundersDECLARfChap JobDescri tion
TION
I hembY affum Wt I em licenud order#.visions of Chapter 9(coy Immix
mm iix p
OZFf� wim5xtiw1deffacDivisionJofm[Busitwsswtl fess�v Cad,aid my cenw is
ow Li[eo Gl. Li[.# t
S J n full face ere eRxt.
u�3 i Dau C.nuscwr
ARCHITECTS DECLARATION
y'n^ 1 undersuM my Plans shill h used m public records
66#0
Licensed PofcasiomW
in, DECLARATION
C Z a 1 thereby eRsm the um exempt
t n exempt from the Comrwtofs License taw for the
c 0 following wan.(Sento-'(031.5,Busircss ere Po&.n Code:Any city a wunry
d3 whichr[quima a permit w construct.dor,improve,.bootie,or repair any awctune Sq. Ft. Floor Area jalgati��
path,isucemad Fran quires movisiosoffor sxh Fermi,wicense aw(obsmem
ma[mislicensed punuws w Ne povuisio of the Canusiness dPunelaw(Cbaga9
lasmm[scingwW Section7")and!
aof n,ban.on3of mBusi[essadon.A,ovr Code)on AP Number Occupancy Type
WI o is 31.5 b mer[fwm and Jte poor for me slkge exemption.Any it panimn of /,Y y Pr Y YP
Section them five
any applicant fa a 00). subjects the epplieanno a civil peWry of
a more ma Ove nundee dollars(ssUO).
C] Required cork. it estroa,amy.'momeeswiNwagnnMe'vw e(See 74)44. madon. Required Inspections
will dom[work,mile: so, is no[imeMeaau,doml fa W apply
Business
andpm .,who
Cade:TM Co....CoeLicense law docs iron apply s if owrcr M
Property who milds or Ackill +.[none and who does such wok deed on a though
his own employers,#avid,WI such impovcmenu an nil inteee a Offered!for
We lf,no«evw dw builde,burden ov mvial t acid wild a oM Wild
or improve
anof Wa.er will love N,burden of proving rust he did not build or improve fa Fur. /f -
poseafWe.l.
L M t she p of me Sm.7 Y•,H exclusively connecting with:)The
contractors to j
wasuuc[me prone,,apply
o an Business and property
who Wionslds
Code:)The Coo rmars. nd
conte law does no,apply je t,owner of propmy who ed p rs improves,mereon.and ^..
who Warrants for such pmjxu roto acantndafq IIC[nse pursuant In Ne Contnno'a
Littera law.
tort exempt untie Sec. .BAPCfor this r,mmn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 Mreby arm under Finally of perjury an of m[following declantiors:
l nave ad will main[dn.ccdifcme orcoment w self more faworlb,"s Compen-
sation,as provided for by Section 3100 of this,labor Code.for Jrc FrHormmme of me,
acme which this permit is issued.
h ve end will mainuin wohims,Compensation Iauemm.as oquued by Send.
3100.(the LOW,Cade,f�rt1he porfofmanu of m[work fa which this permit u issue.
Mr w.n.�!m %V0 `an'ro1cyy No.'[/GsXW6161d
cameo�1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This xxxm.needna be completed ifine#melt in fame,hundred ddun(SIM)
or las.)
I certify that in the performance of she work for which this Ferre,is issued,l shell
out employ any person in any manner as,as to became subject t.the WorkersCompen-
onion laws of California.Date
APphreat
NOTICE TO APPLICANT.If.after making this C[nificam of Ea[mption,you should
become subjxt w the Wake's C.mpensmlan Pursnoonr of the labor Code,yw must
fmnhwit n comply with such provisions or this permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
Q O I hn[by affirm that mere,I, Wr unamcm lending agency for the perfamwu of
.Zi Ne work for which Nis Permit is issue(Ser.3097,Civ C.)
F. LUMer,Name
a 7 lacers Address
ter: 1 unify Jut 1 have rad mia application and erne met the move,infosmnion is
0. correct.l agme to comply with all city ud county ordinances ab sou laws miming to
rti Z building coowction,and hereby aumodu upexaminiv[s of this city to enter upon the
U 0 ahmvanwmiwe property fa inspection purposes.
fz F (We)agree w save,indemnify and keep mmnaless the City of Cupertino against
V liabilities,judgm[nu,cosy ud[xpcmes which may in any way accrue against said City
�.. W in consequew[of the gond- f this P[mm.
F 0' APPLICANT'UNDERS'IA AND WILL I'(IMPLY WITH ALL NON-IY)INT
V z SOURCE faiGUTATIO 6
Sigmurun Uf ApplicmuCmn Data
HAZARbeS MATERIALS DISCLOSURE
Will ft applicam or fnum,building Occupant store orhaMle haalloas munid Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.12,ud the Heahh and Safety Type of Roof
Code.Sectimn 25532+)? / YP
❑YIs CWN
Wim me applicant or raven Wilding xcupant sae equipmrcm adevicex wniln All roofs shall be inspected prior to any roofing material being
mi,hewdmasair comamian,sas defined by the Bay Area AG Quality Management installed. If a roof is installed without Inst obtaining an inspection
tee^°'?
❑Y,s d / I agree to remove all new materials for inspection. Applicant
Ina ereaddrhan<danmm[rid �m;
amwmenm
ad Chapter 695sfts,Cai- un erstan s and will comply with all non point source regulations.
tomo Health 4 Safety Code,Sections 255U 25533 and 25534.1 undmsuM that if me 2191M
WildingdoeI I. rrmJy luv[aunyY at it is mY sr-sPornibilirywmtify tic occupant U
of me"mr,I is vhichmust npriormiumuceofaCmfyaa pa
L Signature Wicant Date
Owner or out x en Dam
All roof coverings to be Class"B"or better
OFFICE