00030137 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: ,I ))�� I AI
(�)
3�/l n/ 1J ��jy� /!l e� gh ///Mer/�/�17 0 x5-AW
� SANITARY NO. APPLIC TION SUQA ITT LDATE
G J ((//� /u �II/U (t iH/Yh// /,253/Vv6)fatlWal)rG� {VAry,I///{/Y«fLLNvv 3 'UROLif t7
Iy//////�//Y////C/'''f Nl0. CONTROLp
10th'.://✓�J �S�-✓1{�,/S' ✓�/! (��- /Ilii V'J 9/V7 ❑
ARCHITHC?NGINHER / l� / '/� BULDING PERMIT INFO
I Qiq�
t hereby air cost IDp OLenNn�ACnder pp�E�MChah�cr 9(commerce Job Description
NSce o 7000)uf D[ aro 3rIthaca .enara "'daman Cede,andmylicenseia
in full force and.ffil t,
5 un.G<� Date ARCHITECTS
ARCHITECrs DECLARATION
1 undenfend my plane shill W used as public recrNa
Ida° U'louned Prefesslomal
¢S'4_' OWNER-BUILDER DECLAMTION
F Z< 1 hereby affirm Out 1 am exempt from the Connmtors License Law for the
In° following mason(Scalon 9031.5.Business and Professions Coca Any city m county
� which rtQYlrea a pare 11 m=muCl'altm.improve,decoutim,of repair my structureSq. f t. Floor Area Value 1 n
prior to its issuance,also requires the applicant for ouch pemuua file uigned wat mens
that he is licensed punemt to the provisions of the Contracbra Licence Lew(Chapin 9
(commencing with Sectors 70W)of Division 3 of Ne Buunen and Prolamines Cndmor pN Number Occupancy'f�� e
Nat he is asempt thvcfmm W the basis for the alleged exemption.A.Y violation of P y •]P
Section 1031.5 by any applicant for a peanut mbacts 0e applimnt to a civil penalty of
nil more then five hundred dollars(5300).
C]L.,comer. We property,mmyernploym.with wageaas Neirsolaaanpenaatim, Required Inspections
will dothawor I Code
oCol.,.'.
ol is .Licam Law
We(Sey to.owner
rof
propnil Profnuom Cade:The Convector's,and w Law saes not appy himself lf ownergh '
his o ny whooyces.ldia or imprvvu thenars and who don such work dedcaor through
W own noses t1,provided Nu such imprvumenu art not intended a offered for,
We.If,hove will
Wilding or impwament is at he aid n t b year of mmple fon,Nt
rwncr-W a.).will Nve tie buNen of giving that W did not W tied a improve for pun- /A
you of ails.).
I,u owru,of ct S..7(AH am exdusivaly cmmseung wIN licenfed...arath on t.
conserver Ne Project(Sec..an [business and Pmfmai Wilda
Crile:)The e.then mr'e nd _may
ceue Law does cutch ro e ts owner of popery wbo W d pars improves demon,and
whom Use-for pmjau with econnu'eor(Olicenud pursuant m sed Convudora
'License law.
❑I em txcmp miner Sec. .B A P C fm thh macs
Owner Due
'1 WORKER'S COMPENSATION DECLARATION
1 hereby a10rm ceder penalty of perjury ore of du following declanotorm: -
1 Wve andwill maintain aCenificue of Conant w self-ins re for Workers Compere
anon;a,povided fm by Section 3100 of the Labor Code,fm the prfomunce of the
efm which Nix Amit Is Issued.
l W will..town Werner.Compensation Insurance.as required by Section
310Dof Nc tabor Code,for 0e performance of the wok for which this Permit u issued.
My Wrkds Co{np�n um 1 w and Policy t1 p�pp@
C.cr: �-I/1'fY ✓✓x1141 Policy Ian:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This se"ummednm he completed ifthe pmut is forum WeshW dollsss($100) ,
or leas.) "
I ccnify Nor in the performance of the work for which this permit is issued.I ahal
not employ any Peron in my marixr all an to bacwru subject to the Women'Compere-
- seta.Laws of California.Due
Applicant
NOTICE TO APPLICANT:If,afar making this Cenifcam of Exemption,you should
beemoe subject to the Workers Compemstion provision,of the labor Code,you mus
forthwith comply with such provisions or this Permit shall be dmmed revoked
CONSTRUCTION LENDING AGENCY
p I hereby aRren thu Vert ie a conumcdon lending agency for perfomonce of
z Ne work for which Nis peanut 4=(Sec.3091,co,.C.)
F. Lenders Name
a > lander.Address
W O I unify Nu L hive rad dna y and coup and caste riot tM above infmcmtion is
iSt building ague to comply with ell city and ofses ordinances andams lawn,Wing to
z mostngcommittee,sonemd hereby
ectiori supos enutivm of Nis city to enW upon the
U ebove-me e) g to t"Yon,.for inspection sn purpses.
Ls Fy '(We)egret b outs indemnify end kmp humins thew City of Cupensro id City ,
U liebilitin,jndgmcn0.cnuand repress whish may in my way accrue against aid City
�. (z1 in consequcxe of the gmnun6 of this pmrit.
�+ APPLICANI'UNDE QANDSAND LLCOMPLY WITH ALL NON-POINT
U z SOURCE REGUTA'If c.
3hVis. s/
Sigmmrt rfApplicmVCon
HA2A US MATERIALS DISCLOSURE
Will Ne applicant or future Wilding occupant store or handle bamsdou.material Re-roofs
as defined by the Cupertino Municipal Coda,Chaps 9.12,and the Health and Salary
Code,Section 25532(a)1 Type of Roof
❑Yea All roofs shall be inspected prior to an roofing material being
-v. Will the epplicmde
[or future Wilding occupant use equipment or vices which
emit hemedoue air conuuninan�Bned by the Bay A .Air Quality Management installed. If a roof is mstal d without first obtaining an inspection
""" I agree to remove all" materials for inspection. Applicant
❑Yea d
I have recd de m.mial.requnammu mate,Chapter 6.95 of to Cali. un erstands and w' comply with all non point source regulations.
forms HmIN St Safety CM Seen.25303,M533 and 25539.1 undenemd Nu little �J)-7
building dmana curtenOY ave ucnvnt.Nat it is my mpnuNlity mnaity,the oaupme / v
al Ne rryuuermn st mu parr mi.evaae ofeCenilicne ccs.
Signature of App c Date
Owneroreuthotmde s Data
All roof coverings to be Class"B"or better
OFFICE