00050017 CITY OF CUPERTINO ' - PERvTr NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUI1.1�GADI)NIibS: "moo �- ^��j�tH 4 G(_�r�s�,/rr/jsfXJ� ! SANITARY NO. APPLICATION SUBMITTAL DAT
OWN[ NAME, C//�g�I I+ / ,7 / /V i rl
NIC CONTROLp
AN Nc: 7/Q� �S^i/ Z ❑
ARCHITECfm-NGiNEER 6 /(� IULDING PERMIT INFO
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N LICENSED CONTRACTOR'S DECLARATION
>,O H I hereby affirm Net I sm licensed under provisions of Chapter 9(commercing Job Description
�yCto wiNSedon7000)of Division3ojtheBmiwsad Rofmi/�ryomyCode.Wnyy littnse is
Cy E,s m tullfomeandaes--;3 (� �C3`ss <�� To �`�''` ! /�f •J �
a i< Licen ass CCS– Lie.N
3 LL N Deta� —Conwcmr
s. O¢� ARCHITECTS DE ATION
u�tO S 1 understood my plans shall ba used as public records
a a o1Jcamsd professional
If OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contrecmrs License Law fm the
2=0 following reason.(Salton 7031.5,Business and Profession,Cuda:Any city or county
W 5_ wldch requires a Permit to construct.a.,Improve.demnllM,m repair am,muctim, Sq. Ft. Floor Area _ Valuation
L proar...siauame.m.,requires not,applicant formchpumittofileesigned auis..' (j7J
Net he is licensed pursuant to the provisions of Ne Connumar,License taw(Cluge,9
(commrncingw!docieon,sold tf bassison3 of alegeinexemWon.Anyovi Code)m APN Number Occupancy Type
Nat he ie exempt thcmfrom W the basis for Ne alleged Gumption.Any violation of /� �s
Section 7031.5 by any appliesnt for a prmut subjects be applicant m a civil penalty of \G'
m more Nen five hundred Milan(5500).
Laownuofthepmpeny,mmycmployerswiNwagmudcirsolecompenratian, Required Inspections
will dothe work,andthe structure is not intended as oHrmd for We(Ser.7D1a,Business
and profeasiom Cods:The Convector's Lime,law does am apply to an owner of
propcny who Wilds or improves Hereon,ad wed don such wools himself or through
his own employers,prcvidad that such impmvemenu are nor intended Or offered for,
ale.If.however,due building m improvement is sold within ane year.(completion,de,
arWilder will have the burden of proving that he did not Wild or improve for per-
pose ofuld).
1,in owmr of Ne property,ren exclusively contouring with licensed contractom to
construct the Mjmt(Ser.7010,Business and professions Code:)The Contracted'.Li- r/
cense law does rod apply m an owner of property wbo Wilds or improves Nneon,and J
who contracts for such pmjau with a conuacourso licensed pursuant in He Contracmfs
License e
E]I renxec Laemq under Sec. .B R P C for Nis reason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby amrm under penalty of pe jury one of the following dxlantimu:
1 have and will maintain is Certificate of Consent e self insom fm WorkcesComPen-
salmn,as pervidd fm by Section 37W of the Labor Code,for the perfonrcnce of the
week for which Nis pamdt is issued.
❑1 have good will maintain Workers Compensation Iwurence,as required by Section
3700of He Laahm Cmk,fm the performaroc of the work for which Nie permit is issued.
My WOrYs(!L Pa tion g,5�at�p sy] eland volcy Noy nu be}n' f• O
Cudcr. "T—a r v— �
CERTIFICATE OF EXE14Pt ION FROM WORKERS'
COMPENSATION INSURANCE
(This Semon need not b,cumpleted if Ne permit ie foro ichurdad dollen(5100)
less.)
I employ
my But in the my mmanee of Na work for which Nia the w is issued I shall
nm employ any Canon in any manner an u m become wbjat W Nc Warken'Compcn-
on aaws of Celif.mia.Dam
NOTICE
Applicant
NOTICE TO APPLICANT:If.+Oar meting Hia Certificate of LampWn,you should -
ha.me,compro it Wmh po Coons in
is Provisions.(Nelabor Curb,yen must
foMwiN comply with such provisions m this permit shell W dared revoked.
CONSTRUCTION LENDING AGENCY
Q Ihereby affirm that them is a constmcdon lending agency for the p rfomuncc of
z = the work for which this perntit is issued(Sec.3097,Civ.C.)
Leaders Name
Leaches Adim.
W G I certify that 1 have red this application and sem that the aWve infomution is
0. corral.I agree to comply with all city and county ordinances end nun laws relating an
.�. z building construction,and hereby audioriu reprcsenutives of Nis city to enter upon the
f) O move.mennoned property for immuon purposes.
iii. F' (We)agree to save,indemnify and keep hemlines ted City of Cupertino against
C.> liabilities,jdgments,costs and eapenres which may in any way accrue uproot said City
[TJ
in con.,equeme of the granting of this permit
IY APPLICANI'UN UP R5TANDS ANDliVJ,COMPLY WI H I ALL NON-POI N'I'
'SigrommemAlldicargContruClOf Date
HA].ARDOUS MATERIALS DISCLOSURE
Will do applicant or future Wilding rccupenismrc or handle he,allous material Re-roofs
as dafined by the Cupertino Municipal Code.Chapter 9.12,red He Health W Safety Type of Roof
Code.Seam.n53200? yP
Ely's S/.
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
l luound.au connminants as defined by the Bay Arta Air Qtdiry Mougement installed, If a roof is Installed without first obtaining an inspection
goarkt7 [ agree to remove all new materials for inspection. Applicant .
❑Yes
Ihe,,nod the lnr&d�mdals reg.inmenn under Chapter695 of He Call- un nds and will comply with all non point source regulations.
fmnu x.16 A Sefey Coda,Senleeu 25505,25533 and 25530.1 WMusund sol if de
Wildiogdoesrmrcunm0yluvcsuwnt lit is mY rapoodbiln tonexa ibamcupant
.f ircmenu wldch must be m usuanee of a CeniIII a o�u y.
gnature of Applicant Date
rte
01
eu ,d agent Date
All roof coverings to be Class`B"or better