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00030131 CITY OF CUPERTINO 'PERMIT NO. BUILDING DIVISION PERMIT CONTRAgTQR.INFORMATI.ON: i BUILDING ADD ESUS, f ,t C1, ` - ©OO'� O/ I�t04' 0 OMS MC1, CoVNI'Nb� , �ka� � s\ �S. SANITARY NO. APPLICATION SUBMITTAL DATE A ` �t x'-22.00 OW ER'SNAMU: ` 65,10 (` .1 C9e Y ca, Vjne fan P,4e/ia.�ktl d `A-' N/C CONTROL« IONC: ln�� `/� �� I'ZA ❑ to y46 -I A4 61 •a , ARCHITECE ENGINEER ,. ^!•� ._p�6 Q BULDING PERMIT INFO a0�a Hoed O 4� LICENSED CONTRACTOR'S DECLARATION 0 o z ❑ • I herehr aRw N.t I ren n[emed.edm Prowiaa.r Ch.pter9(mmmeming Job Description FyF•w n aft Scmion]00o)ofDivisia3ofshe Busin<u seed Rofevionv Code.aM mY liana is 5 I �O5 ifull form W eR ct. au Limnse Claca Lic.N '1 Q_el�lcice -�ur�fLce N.C. u aO< Dau Cc ARCHITECTS DELL®ATION T, v 1 undanraM my plane atoll be used as public records -►J 4'N Q.<@ = 1T) i a Licensed Pmfeuimul A • (, -T OWNER-BUILDER DECLARATION 4- I:'6 6 1 hereby aRw she,I em exempt from she Contractor's License Law for the f'S O fallowing r[acon(Sm t s Tom s,d.mass end Professions Cad[:My city le. r many u'Yi C which ns i..a Pewit so command.eller,improve,demolish, fi repair mY awcove 3m tender to Sq. FL Floor Area L Valuation that heislicewit punuam to00)the Provuiasof,heaEast.r's Licenulawma Co,k)q / _ VU feat he ingwo hSecond]o00)ofbasiia3 oft alleged exemtca.Any vilm000f APN Number Occupancy Type, Nat he is eumpt Nertfmm end the bait for 0rc alleged eeemgion.Any vio4tion of p Y Yp Section 7031.5 by any applicant for a parent subjects she applicant to a civil pemlty of X 0 I O nor mom than five hundred d.11.($500). ❑ Lasnwarof,h[propany.mmyemplWmvwimwagmwm irsol[mmpeaNm, Required Inspections will do the wmk•M Neawcwrc u nor imended a.Rased fm rale(Sa.TOM,Buaiau and Pmfuaiom Code:Th[Coanutai License Lew does ms apply,o m aware,a property who builds m improves threaten,and who door such work himself or through - his own employees,presided Ow such improvereems am no,inteMed ce.Rered for We.If,however do building or improvemem la cold whom one you of cmamletia,do .wanbailder will hove 1M burden of posing Nat he did nor Wilder improve for pm- I,as owner of the prepary,am exclusively.tcommoncas Car licensed!cmuaton m 6 / counteract desb. nor tartly Busmenend Fy,who ore Coded The Conuands Li- /'1 cense Law does nut apply je ta owner of ewcony who builds er improv.shemon,ear's `/o who se,Latsfm such projecu wiN•conraamdq licensed Interment to Ne CAnBa,dt �/ Li mem Law. Q lean exempundcr Sa. .B kPCfor this upon - Owner Dam - WORKER'S COMPENSATION DECLARATION I hereby affirm under peaslty of pe Jury con,of the following declarations: I have Ind!will maintain aCmif calk ofCohuenrto self-insene for Workers Catalan. cation.u provided for by Section 3700 of the Lebm Cade,fm,he perfumrenm of,he wan which this pem,it is ismed. [{I have mW will maintain Workces Compensation Insurance,u required by Suction 3700of Ne labor Cade,fm Ne P[aformaae ofthe work far which this famett is issued. _ My Worker's p u m, nanrsme c 'a etW Policy number y�. Cmdcn `A Policy No.:u ab`+kf 4f ry F CERTMCATE OFEKE ION FROM WORKERS' COMPENSATION INSURANCE fThis union nadeca beconnsd ad ifthe pemtitis Rana huhWrcd dollars oloo) or tors.) 1 certify Nat in the Ndowaa[of the work forwhich Nie paredt is inued,l shall not employ my person m my manor co m m banana subja,t.N<Worken'Compn- sa)nnLaw r fCelif mi«D APP icml NOTICE PLICANT:If,afar making this Cenifieae of Eecmpnm,you Mould hewme cobl s m dm Wands Compewsia provisions of Ne labor Code,You man faNwiN comply wiN such previsions or Nis permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY O Q k for whaifw Na Nem iasmmtwcN3W7.Cev.egeayfor,he perfnmwmof Z 4 Be,wank for which Nu permit is issued($ec.309],Civ.C.) E•r IaMeYS Name �i E IaMei a Addles [aI Q I certify Nm I have rad dna application nM aWt Nm Barand shove information is 1 cunei,.Iagree mcanplY were illcity and awryawives of this eau lawse ulongso U Z building construction,real herebymNndnrepeunwivn of this city to come upon Ne IJ P abovtmemimud popa for impecdapuapout. ra.C t o (We)agree w cent.indemnify end kaP h y in m w City re Cupenim against C.1 I.couserl.man he cents ground,eepmus which may in mY waY amus against aid City ,�. Lit inPPLICANT N ESTAof dna permit. .Fi '0 APPLICANT UNDERSTANDS AND WILLCOMI'LY WITH ALL NON PoINT V Z SOURCE.REGULATIONS. Sigrutun of Applicm sur C Data L I.9w7oa.UGLf HAAZAZUUDRDOUS MATERIALS DISCLOSURE Wil by teCuffant or fMunbful ingampaptnmeor hurdle hazardous Safety Re-roofs as m.definedSec by the Cupertino Municipal Cak,Chapter 9.13.and the Hastert seed Safety cnee. 0Yessss3xan f./ � Type of Roof ❑Yrs L7rvo Will the applicant or for..Wilding occupm,esu equipment or devices which All roofs shall be inspected prior to any roofing material being •mil heuNo6s ab conumn inena definal by the,Bay Ana Air Quality Management installed. If a roof is Installed without first obtaining an inspection correct? ❑Ya I agree to remove all new materials for inspection. Applicant Ihave rand the laudations mnnlla m mmnunder Chapter d95oftheCali- unclerstands.and will comply with all non point source regulations. Barin HuIN Ar Safety Calc,Sadms 25505,25533 and 2]5M.1 mrdnsund 0w if Ne buildiry does tw correctly have BArrom.than i.ie my mponsibilityinmedythemuvpan, ofthe " mama wNchmum IM oft Cenificue oroccupuwy. SQ Jia On -� t,au Signature of Applicant Date 1 Ow r ramhonzcA agent sS Dau All roof coverings to be Class"B"or better OFFICE