00050110 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOWINFORMATION:
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[;BUILDINFA�DDR�S: _ l1l����f�O �U /1USANITARY NO. APPLI ATION SUBMITTALDATf
R'S NAME: { r- C7O
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CHITECT/ENGINEER BULDING PERMIT INFO
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I_H i LICENSED CONTRACTOR'S DECLARATION
I hereby anwn Nl am licensed under provisions of Chapter 9 koonrnc.ing Job Description
Vi<m(:uCi with S.d 7")aDivision3ofthe BusirmssnM fusions Cog mylicenwis
Y x I� in hull force aad ellen. ^^
s Lice se Clan Lic.• �Q- ( T (
QO( e �W,,..dtlIYel
3 LL Dam Conu.cwr
LLC ARCHITECT'S DECLARATION
g 1 understand my plans shall W used as public recons
lee
Li4meed Profeniavl
OWNER-BUB.DER DECLARATION
I-Z m a 1 hereby anion deal 1 aexempt from Nm
e Contrtors Limmm law for the
i �M< following...(Senior 7031.5,Business mad Profmiona Cude:Any city.wunty
w_m which rtu's wto qa permit emnwcor
et.al ,improve.demolish,or repair any awcmre
1322 pride tolOissuance,ales,"tures thea applicant fWmettpewitmfileaSigned NtLment Sy. FL Floor Area I G Valuation ��Coa
That he is liccmed pnuanuo the provisions of the CommutatorsLianas law(Chapter 9
(commencing with Section 70001m Division Sof Oe,BRSIK,dust Profenioru Cral an APN Number Occupancy T g
that he is exempt therefrom and the batia for the alleged exemption.Any violation a �I P Y YP `_ -s
Section 7031.5 by any applicant f.a pewit subjects the applicant m a civil penalty of L 645 Itl` o I I
pof more than five hundred dollar(5500).
I,n ewnm erthe preprty,err mr employees with w.get,weir ante emmpmadon, Required Inspections
will dothe work,and he swnure imor interned eroRer d for We(S«.004,1.Business
and Nvfeavem Code:The Committee's Licene,law docs mer apply Is,an ovncr of
property who builds or improves thereon,and who does such work himself or though
his own employ.,,provided Ws such improvememta art nm inmMed a offered for
We.If,however,the building or improvement is auto within one yearof complasion,the
owner, Ihim will have the burden of proving that he did not Wild.,improve fw pr-
I'ae o a.). of the propenY•am<xdusivdY conmmtin8 with licensed wnmicton to
cenmosthe project(S«. Business and Professions CodcJ Tim Convmmi s Li-
ses LaLk w docs min apply r..m of property who Wilds imptovta th«enn,and
who contracts for such proj«ss with
a a contractor(s)licensed pesrsumuu Ne Contractor
1 law.
01 actprtuMcr s«. .B&Pero this
Ow n Dem Qe 1004'e/
WORKSIIII. COMPENSATION DECLARATION O
1 hereby anrm a sed'mf perjury one of the following declasatiom:
]In.as aM will maintaineCion 37 m of the La for
Workdace of the V
,tion,as provided for mi Section 3900 of the Labor Codc,fmr the performance of the
work for which this permit is issued.
❑I have aM will onde,for y, divce,Compnwip work
which
h re,his m d i Section
My stinthe.C.Code,for Ne pertwmance of the work for which Nis pewit is issued.
Ca Wwters Compawtiw insuwme carrier add Policy number art:
Ceman Policy
CERTIFICATE OF EXEMPTION FROO
M WORKERS'
COMPENSATIONTIONINSURANCE
This section need not be cnmPlnM if the pewit is fwone M1urstrtd dollua 15100)
.ku.1
(certify that in the performance of the work Ode which this permit is issued,ishan
not employ my person in any manner m as m become subject to the Wmhcrn'Comprn-
Ap Applicants laws o(Cdifmmia.Due
NOTICE TO
NOTICE'ro APPLICANT:IL Cmrnutting this Cmit.ofth Utter Case,
wuM1mot
asuld
home h compel o it Workers o Compeor this provisions of the labor Cade,. must
fuMwith comply with such provision or this pewit shall be d«uoest revoked.
CONSTRUCTION LENDING AGENCY
p I hereby affirm thin then is a conswcuon lending agency for performance of
z the work for which this Famous is issued(See 3097.Civ.C.)
2
Ew Leaders Name
Undeh Address
GilE I certify that 1 have read Thu applicmion and awe tMr the above infomution is
a, z correct.I agme to comply with all city and scurvy cedinmcea and state law,relating ro
Z. building conswction,and hereby anchorite representatives of this city to enter upon the
U above-menrienr4 property for mapcctiom purpous.
ri. rr (We)agem m save,indemnify and keep hawlen the City of Cupertino against
O U Iiabilmasjudgments.cosDasM expenses which may in my way su meagamt said City
in consequence of the grmling of this pewit
[-� d APPLICANT UNDERSTANDS AND WILL COMPLY WI I ALI.NUNIroINT
SOURCE RI:GUI.ATIONS.
� z
$I,..of A,IicmuComtutm Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building excupm store whmNc haraamus...end Re-roofs
O as dermcd by the Cupertino Municipal Code.Chapter 9.12,and the Heilth and Safety Type of Roof
Code,Section 25532Q)0 YP
B ❑Yes XNo
Will the applicant or fumrt building meander use equipment or devices which All roofs shall be inspected prior to any roofing material being
amt n ora dreonw imentaasdefinedbydbeBayAreaAtiwdilyManagement installed. If a roof is Installed without first obtaining an inspection
Diamkr9 I agree to remove all new materials for inspection. Applicant .
❑Y. �#m
Ih..re.d Nelwardw,mamrWartgminm.Ia ender Chapter 6.95 mfNe Cali-
building
understands and will comply with all non point source regulations.
fomite Health o safety Code.S«timu 25505,25533 tad 2553,1.I padmuad that if the
building d.x nw currently M1evc a tenant.Nar it is my rtxponxibility in notify thea wcupnt
of the mluvemmu which m,.i W met perch to issuance of a Cenilicete of Occupancy.
Signature of Applicant Date
Owner or awhonaed agent Dam
All roof coverings to be Class"B"or better
OFFICE