00030030 CITY OF CUPERTINOPEWUNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: �bd 30050
BUILDINGADDRESS: /I Q� W4,t4,
3 n Pel e r/1 ��//�w��/J W SANITARY NO. APP�A� SOB,ALDATE
OWNER'S NAME, P,O• 06a 1/0? OL
(C NYC CONTROLM
PHONr. 3• ❑
ARCHITE ONGINF.ER - �� � qla�� BULDINGITiRMITINFO
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LICENSED CONTRACTOR'S DECLARATION
OZ=` I henby.M.Nu I an licensed under previsions of Chapter 9(commercial, Job Description
r y C uQ will Sectioa]000)0(Division3 ofthe Busiaa..d Pofasioor s�l he Nassau s'
<yEJ infullfor«eMcR«t.
y m w U Llan«Clan Lb.g
% °'l.. Deb 'Moomr
C�O g ARCHITECT DECLARATI
5 v�y� I un rt no Clam shell be u.W a Wblic nards Pff
s'I /7�1 ' 1 ar•4L /1
ago Licensed Pmfeuimul f'F�AL� �_J.aV ss,>IT///111'��` f�����..•JJI������`
u1 OWNER-BORDER DECIARATION
t Z< 1 hereby ft,.dol 1 an exempt from Ne Contractors License Lew for the
Z❑ following....(Section T031.5,Business and Rofeasions Code:My city a county
C which requires a permit to conswet,eller,improve,demolish,or repair my suucoue
a_ Sq. FL Floor Area Valuation
prim no ib iaumce,elm regains Ne epplicam fm.uch pemdl m file sang^d euumem
Nal he is llcemd punuantta Ne Previsions of Uk Conrr.mora liana 4w(CMpmr9 ��
thamm is commit
oral do basis ar N Bmina.apti.e. .,in lam.of PN Number Occupancy Type
Ifni he is 31.5 b Norefrom end Ne bars far the alleged exemption,Any viol.dm of / / + I� O p y yp
Section 10l LS by any eppgcmt for.perduubjecte Ne applianuo a civil penalty of o FV. ( - •V1
not mon Nm fere hundred dollen(SSW).
01'.. Required Inspections
will Bothe work,and Nesmtcmre is not intended oroRered fm We sce,'/Oxx,Basins
end Profession Cade:no Convector's License Law does net apply to an owner of
prepeny who Wilds or improves distant,and who does such work himself or through
hisW own employea,Provided Nor such improvements w he no intended«offered for
sale.ILhowever,the Wilding aimprovement It sddwdid t build
the
ownttf"Is) will love the buNrn of proving that he did not Wild m improve for pun
you of aleJ.
El 1,rc owner nj.. property,.m sinus rel Foouanninq Cwithod 11«md conbecron -
encore die es jn(appl(Suoy
o an owner of
Property
who
buress Cede:)Tie vesnuemMe li-
wholaw duns trot apply to ts owner of property wW builds or improves Nerer c and
who Law.for such project wish a conuecmdOlkenaed pursuant the Contractors
License law.
❑1 am exempt seder Sec. .B A P C for this rtaon �/
Owner Data
WORKER'S COMPENSATION DECLARATION j
1 hereby affirm oda prndly of perjury am of dm following declaatimn:
D IMve.dwillmain m.cautifiesecaCome^noself-marefetWorker.Compem
union,.s prnvidd for by Section 37W of Ne Labor Code,for the perfoman«M the -
work fm which this permit is issued.
D 1 have and will maintain Werkces Compensation Insurance,M tego'ued by section
3100 of Ne LabmCab,for tW porfmmatRe of Ne word,for which this comil is issued.
My Worker's Cynlse,0Win playurg�G canner and Palley nuupp{{��y�i+try�/ ,
Cartier. G7 Policy No.: ATV �Y
CERTIFICATE OF EKEMPION FROM WORKERS'
COMPENSATION INSUMNCE
(Thio vection madam becomPlow!iflhe Carrel is 10rtm hundred dollen($100)
or Ie..)
1certify Nein the pedwmaxx s st wmkfor me, permit ns'CoIshall
ret employ any Canon in any men«r m as to became subject un the Worken'Commn-
utile Leant of California.Cue
Applicant
NOTICE TO APPLICANT:If.co making n certificate o of Exemption,you slroulin
home subject y it Warh ro Compensation govit Thal of tde labor Cade,you muse
forthwith comply with reel provisions or this pennin shall W dared nvorkW. '
CONSTRUCTION LENDING AGENCY -
0 0 I hereby aRnn that then is acomwe0on lending agency for IN perfomume of y •_• % _�—
die week for which this permit I.issued(Sec.3097,Civ,C.)
Lenders Name
.a > laderi Address
Gil 0 1 c.,fy that i bawe need this application ad we NSI Ne above infumution it
�1t In.t.l all.to comply wish ell city and..aty mdimnca and is,.lawn meting to OR 0 3 2000 U
r7 z building conabuction,and hereby audiori«npresenwives of this city no enter upon the
C.) G above-.fiord property for inspection pupou..
toe. Fy (We)egress,in ave.indemniry and k«p hamlet,the City of Cupertino 18"t
V liebilida,jdgmenu,cornu andpmeawhich may in any way acreat said City fly
�y incanregam ar
fr
o
,a his Permit
a..a N APPLIC TU ] DS, NO WILL COMPLY WITH ALL NON-POINT
N. `,'�✓`) y
Sigtwun of ApplicanVConuenmDate Joe AW/�AL�Cc,
HA] RDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupier tmrom handle aanrdw.material Re-roofs
M defined by the Cupertino Municipal Code.Chapter 9.12,and Ne Health ad Safety
Code.senior,2ss32(.)? Tom. Type of Roof
Dy. W^
Will Ne applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emilhaardoeeaircpnmmin.nbas ondbylheBayAnaAbQu.lityMm.gemcnn installed. If a roof is Installed without first obtaining an inspection
No I a ree to remove all new materials for inspection. Applicant
t DYa
Rane uh td a"tummuennadarClows,6.95.1'th di. understands and will comply with all non point source regulations.
rami.NUIN Safe c iron 5,LSSA ad 2553x.1 undersand Nu if the
Wildingdoe cu L iththyropossibilitymn ify eceupant
of the noun' whic st m ' 1.its of.Cond. t my.
Signature of Applicant. Date
Oona m euNonoc l agent Dab
All roof coverings to be Class"B"or better
OFFICE