00030001 CITY OF CUPERTINOPERMITNO.
BUILDING DIVISION PERMIT CONTRACTORJNFORMATION: 000.3 000
BUILDIN 3SviSS; R_{.I L. L-te s c owsrpgJCTt01.� SANITARY NO. APP ICATIONSUBMITTALDATI
I°I31$(31..P►+It,LI+•/J 6100
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. R'HI'TLCT/ENGIN[[H BULDING PERMIT INFO
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,�i LICENSED CONTRACTOR'S DECLARATION
ZO Z:o I hereby aRrm that I on,licensed under provim as of Chance 9(commeaing Job Description
HH=J with Section 7000)0(Division Sof the Business ad Prefeuiom Code.gd my license is
in full force read c• /•
On< D .e ut, hC154A r✓ ' ,Ka/��/ — �MP. IGgo
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a t- Date Cops _
ARCHITECTS DECLARATION //]] z� /' 11
fly / Iunemun�INy arWl huaedupubli<recvda 10 SV�I09 r I/I�I% V,60 }r
OWNER-BUILDER DECLARATION
IS-Z_a I hereby aR W that I am exempt from the Contractors License Law for the
dr�C following reason.(Section 7031.S,Business and Pmfersiona Code:Any city a county
F m wh' 'res m comWd m¢q improve,demaliah,or rtpur any am.
s.3_ Sq. Ft. Floor Area Valuation
q li fn < f reed em
9 �_ Q
Na a n Pru n L �JQO 0
a T
on APN_Number OccupancyT e
wt e h aemp ruts 1 �-s1 �.. YP
Section 7 1.3 by en eppbrmt for a permit subjau the appbcent civil of
p La ar y. m" Required Inspections
wthdo n i "t est.
gn
a dPro d
w Wilde a,imPravea thereon,w who sore ares ak m throa
credfor
' oRrtd for
r- tl 1 ing
l a is�led t t fa
posee.. t■�
I,u owner O the property. m scaduaively voting wi Ice to
project j
construct the t(Sec.700e,Business and Professions Code:) e Comab
ae Li-
corse law da:e mn apply m an owner or Propery wbo builds or imaova theaon,area O
h contracts for such Projau with econtnnorf0licensed Pursuant mthe Convenors O
ma W.
co
mptuder ScBRPCfor this reaaan
Ownere/ — �JDau �•pg•00
RICER'S COMPENSATION DECLARATION
1 hereby affirm under pcmlty of perjury ate of don following dalantiam
](hive ad will!for
of CoruenuoCode.ante a Worka'a Co of the
tion.r provided fpe so Sections 3]00 of the Labor Cade.la the perfonrunce of the
wok for which this person is issued.
FI I have and will ode.fon worknrs aim,ofvtion work
for nce.which
h rtquirtd by Section
My orleelabor Code.for the perror careoathswwk forwbich Nis permitu issued.
My Wmkcrs Compensation Insurance cassia and Policy number are:
Gorier. Policy No:
CERTIFlCAE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 7MA
(Thiaaectinn nadna becomPleted ifthePrWitie foronehvdmd dollars(5100)or less.l I cmify Wt in the pedorenancy{f the work fur whicM1 thio pemtt is ieavaL 1 shillI 1notemploy penonm e 3d es to havnw subjano the Worker'Comate- Usminn Iowa Califoma. are 12000
Applicant •NOTICE TO APPW.ANr:IL afmr nWdnB thir CenlRnu of EaemWon.You almuldbecmme aabjatto Ne Workers Compensation provisions of the Labor Code.yen must
forthwith comply with such Provisions a this permiulall be danond rooked. B`ICONSTRUCTION LENDING AGENCYJ ���
O I herm,affirmlNl them is.construction lending.gen<y for the perfo.of
Z the work for which this permit is issued(Sec.3097,Civ.C.)
4. Leaders Name
a } laaders Address
WI certify that 1 have read this application and sordm' u
e ththe above inti mtton is
Aa z correct.I agree to comply with ell city and county onlinances sen,Out laws reldng m
Z) L building construction•ad hereby authorize representatives ofthis city to enter upon the
U 0 abuve-meminnd'oo,ny for inspection pumoaes.
W F (We)agree m save,indemnify and kap harmless the City of Cupertino age=
O C.> liabilities,jodgmems,emu and expenses which may in my way amore against mid City
} (z7
a.con.quncom of dhe gremong of this permit.
F .. APPLICANT UNDERSTANDS AND WILL COMPLY WI'I H ALI.NON-POINT
V SIlU CERBGUI.AF NS
Sigtumre of licam/Comruta Date ,�e— /'-J ti70n-Uwe, a
IIA]sRDOUS MATERIALS DISCLOSURE
Will the applicantmtumrt building..Pa..,aeor hoside bazardaus material Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.t2,ed the Health mal Safety Type Ot ROOT
Ya Ewa
Coe,O 2553215532W7 _ YP
Will the,applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit hedma air comaminenu as defined by the Buy Arca Ab Qushty Management installed. If a roof is installed without first obtaining an inspection
vinowYa a I agree to remove all new materials for inspection. Applicant
Lh.ve mare the hnudwa materials mlairemenu oder Chapvr693 ar Nc C.li- understands apc�will comply with all non point source regulations.
forma Ith n So rms C 25503.is my o,25534.I understood INI if the / /�
bauai ream tea eareno y.ver to t.thmhia my reswmibiurymmairr me ocrawnt V r 3r0/
of Uhe vemmu which t tierce ofa Cmifcue oftkcupmxy.
VJ Signature o Applicant Date
net or authori .gent Dare
All roof coverings to be Class"B"or better
OFFICE