00050045 CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION CONTRACTORt;INFORMATIO, T,;
BUILDING ADDR'
/ U I � 10 SANITARY NO. APPLICATION(�S"UBMITTAL DATE
V-aq MART r /—.PWAQ
R'S NAME:
•Z 1��11I�-�lL.�-. NIC CON//TROXL(MIdli
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H�aN.. W�I G+�I INJ OI GV LIV 9L.I�OI.ILI�" El
2,51 -24UD
ARCHIT[GT/E GINEER ^ 5- — Z I �,y5 O �� IULDING PERMIT INFO
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F i LICENSED CONTRACTOR'S DECLARATION
z O Uv,— 1 hereby aRrm Nat 1 sus licensed under provisions of Chapter 9(commencing Job Description
of—v
F`=Cw wish Section 7000)ofDivision3ofNC Busin<ss,nis
6x7.- intullfoaeundcRect.
�aew 6 Lee. Ila• T^C lt,kill/Gill trri^^ 1 ,'
3 i Date
Con i � -5 ?L A-59l U` 1.V) 7-11 1 >��I ��• �� �a
C O 6 ARCHITECTS DECLARATION ,—s I 1 1 ,a n f•�`/
S w Q o 1 undersand my Plans[hall be used u Puhlic records a!- fz Dt — � w C ei k'_Al--ate 1
N a
6.F4 Licensed Professional G. 1�g..a/ �[-, r {s,� C ^ / `'
uxi-— OWNER-BUB-DER DECLARATION R"1�- D Eke-- ` ✓tf2_k V w / 7
(_7�a 1 hertby a1Bnn that t am esempt from the Co.,.,&,License Law for the
S O following reason.(Section 7031.5,Business and Professions Curie:Any city or county
el i 3 m which roquirts a pewit in camwn,alar improve,demolish,or repair any[wcwe Sq. FL Floor A / luatlon O
prim to nsiauvn«.alw rtquirts the appli,[lin for such pemut mfileasigad aatement
Wt ere ix licemed pursuant a the Pavisiii of Nc ConlaaNe nd Prof law(CTupa r
that hcua ingwithicieft. itdiDivisionr ort he BusiMssand Nofeniwu Cade)m AP Number
thus he is a`mpl therefrom and the pair for the subjects
thA exemption.Any vipav,I of �^
Section then by hu applicant ton pewit mbj«ta Ne applicand to•civil perult �.. vVLL
t mote Nen Eve hundred dollen(t5O0j.
❑Leftworoftheth se c,.rmye intq moffe gesaYmh=,7Wye Required ec[ions
will dothcwines Code:`[wcwrtisnor im`Med aorto nfmura(pl,7Ban,Bualaa
aro Prolamines
rof whob Code:The Contractor's Liana law does nor apply self r wn through gh r
his oof
ny who build[or improves n lith ,and who rias such work deed ce,m through
his own however.
de provided that such...is it w are ren intended ur olreme for
owner- ildevem da Wildingoren of prvind is sold wiNinaaywfirrEolesm,da C a
poc o Wild«will have the Woen of paving that he did wl Wild or improve fa pv- G�L
pof sole.). r1
I,a own«or Ue property,em exclusively conbating with licensed caoscmrs to .
com.uct the project Sec.7p.n,Business and P ofesaiom Coee:)The Convector's U.
tenor Law does nor apply m sn.war of property who Wilds or improves n.soul
wlweonnvetsfasuchpmj«uwithacunmetor(s)Iicena pursuant to the Contractor.
Licrnse Law.
❑Iron exempt under Sec. .B k P C four this twos ,��- *0O �O
Owner all
WORKER'S COMPENSATION DECLARATION e�'4
100
1 hereby aRw under penalty of perjury one of the following declarations:
I hove als will meso u t aCenifieau of Conanl to ser(-insure for Worker'.Coupon- O'
inion,as provided for by Section 3700 of the Labor Cade,fm the pedinins.of the H�
work for which Nis pewit is issued. y
have aro will maintain Wildo,'a Cwnpenulion Imurarce.n rtquuce by Section
my WorkaofeLanae Code,(ath`perfowanneofthework fawnicn Nis pewits jawed.
ers Comm
pealion Inmrutea a
c coria Policy m
nubte
er e:
Ca
Cartier: Policy No
FROM
CERTIFICATE O OF SATIONI NFROM WORKERS' ,
COMPENSATION INSURANCE
(This senior nmd nor be completed if Ne permit is foroahuMned rid Ws 13100) ,
or lea.)
I candy that in the performance ofthe work for which tniapermit is issued,1.1call
d employ an person in eny menano an abj«t eo the Warkerz Compen-
tiov lawa' IifomiA Date O D
Applicant /ICAN!l i
NOTICE id l 1.the NT: r.Cher mani g this Cervu,nocau of Exemption.you should
A«ome womply it Worharo Comas or this pmviaihal of Ne6eWr Code,you must
forthwith comply with lath provisions or this pewit.hell W domed revoked.
CONSTRUCTION LENDING AGENCY
O Q Ihereby.Rnw than Nen is.consnoutol lendingageoly far she performance of
Z y the wink for which Ni.pewit is issued(Sec.3097,Ci,C.)
E..,, Lenders Name
a > IaMers AddnsR
I certify Nm 1 have seu N
d t application and Rude at the above iMomalion is
0. zcowct.I all to comply with tel city W county aoinarca W nus laws relining m
Z z Wildingconsuucuon,aro herebyaifloone apesrntativesof Nis city to a......the
U O abovrm`mloned pmpcny fa inspection purpoaa.
W Fw (We)agree to ave,indemnify and keep hawlem the City of Cupertino against
O U liabilities.judgmens,toss not expmaa which may in any way«nue against mid City
} fist in c aqucae of the grunting of Nu pewid.
F' O6 PLIC T UNDHIsIANDS A NO WILL Oh1YLl'WITH ALL NON-POINT (1 _
V 15 S()URfVRFGU1 NI IONS.
Signatwcaf Applicwtt nusc
RDOUS MA LS DISCLOSURE T
Will Ne eppli ant or fvwm Wilding oecupm[lorcalaMlc havN...material Re-roofs
as defined by the Cupertino Municipal Code.Chapter 9.12,mW the Health wd Safely Type of Roof
Code.Section 25532(.)? yP
oReNe.pPRcaol.rfu❑turt Wilding«eapwtaae gaipamardevices w:inh All roofs shall be inspected prior to any roofing material being
emit hnrd
aouseum
ir coninmu as defined by the Bay Arta Air Quality Morsecmcnt installed, If a roof is installed without first obtaining an inspection
Aftak'sonct, I agree to remove all new materials for inspection. Applicant
Yes No
I have mad the hallow,material.requirtrana under Chapter 695 of Jte Can- untie stands and will com ly with all non point source regulations.
Tornio Heel sefetY cage.S«liom 2.505.25333 rn 25s3..1 dollars lead Not iif the G/p
Wildingd s cummly neveeunnnt thy�t is my mibiliry wnotify the ecu t
e t w ' must be urcI plLQu is eafaCmificatesifocc
`7�J fo ignature of App ' ant Date
Owner or eudmrixedagor Da
7JEy�fL j -asAll roof coverings to be Class`B"or better
OFFICE