00040077 CITY OF CUPERTINO PERMFTNO.
BUILDING DIVISION PERMIT CONTRACTOR"INFORMATION:
000L1, Oo�
tlU1LUING ADURFSS: � ) /� _l
SANITARYNO. APPLICATIONSUBMRTALDATI
...IrNER'S NAME: CR:aY� " '
CONTROLp
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5A -rA C-647r,,o , CA IFl`r
t ARCH I'I r:CI'/ENGINEER ISIILDIN01'IiRMI'I'INFO :y^%
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F 7 LICENSED CONTRACTOR'S DECLARATION
ci E Ithereby aRrmthatlarm liconxdunder poevisiauofChap«9(conmreming Job Description
wiNSxrm]000)OfDivisianJafdes Busimssand Pof<asiors Cade,and mYlicomcis
x e,S in full force and
m License Class�L`LLIc.N l0 / C7
d Dam-L O CM DECLARATION
O ARCHITECTS DECLARATION
I understand my piens shall be used as public records
p
u S o licrnmd Professional
OWNER-BORDER DECLARATION
I-Z< 1 hereby aRect on lam evempe from Ne DO.aeemo eLicense Ac Law for the
s D following realm.(Section IDs I.S.Business and Pm.&.Ji Cade:Any city a county
wNcM1 2gdxs a permit re eomwe, alcor,impose,h pero N,or any rwmue
`v 3 w Sq. Ft. Floor Area � Valuation
prim tot ficeuadForsomgolms pr applicant for ruchPmdt miter.le a ew(ivel Hamear9ement �)
demom.i.,iedpursmm mdespmvivision 3 NeCmiomoend Fort i Chapc9 �U�V
that he
engwith Sadon90003 ofDivision]theseegoinexempton.AnymYCude)a APN Number Occupancy Type
wr fie is exempt thacrmm w the basis for the.uegnd exemption.Any vieslatim of p P Y YP
SectlOn 7031.5 by any apploom f«a penin subjects the ap,Iicmuo.civil penalty of31C-06- O yL 316-- OG- d-/
pm more than five hundred dollen($500).
I.as owner ofthe poperts or my employees with wages as their sole compemadon, Required Inspections
will des Ileswork,Cocke. he Comisn«intcndnduraw dofar sale(Sec.]INC. wnerof
and property
who
Code:The Commune's License and w Law does v apply s lf«vnm or
property who build,or impmva Netcom and who dos such work himself«wouee
his own emplOyaa,pmvidnd that such impavemenu ue not intendW or ORemd/or a'.
I
de ,4atild7wiNc buil ding orimpf Moven is he
did n not
to
prove for por. S /� /
oive,of ldm will have the,burden of Coving that fie did nut Wild«impose for p«-
Ces•e of ole.).
Cl
1,ax swot of dse propcny,an cxeluslvdy contacting with licenand mnaanom res
cnmsuct the project(Sc<.elan,owner
of and rt, ho m Cade:)The Contnctol. fid OO
come law does rot apply m en.Bmr mi and Po wbo milds a impavn thereon,and
who contracts for such poj«s with a conoacsodx)licenand pursmnt in,des Contractor's
Li fir Law.
❑1 em aemPt under SQQce. // .B @ P�C�f«Nis rcuon
Owner�l_L)Z!/R.t Date 12-02 ��
WORKER'S COMPENSATION DECLARATION e
1M1and waffirmunderpenaltyamperjuryoreof Nefollowingker'declinations:
J I have an videed for by a sous 3700 of C Latin Costs,sor ft Mdrker. f,h-
workf as povidW for by Basion)]00 Of dm labor Cade,for Ne perfomume of the �� �e
work have
which Niaemmtis issued.
1of astdwillmaintain Compensation for as which this
Section
3100af the labor Code.f«Ne pcAmnsure of do,work for which Nis pcemit is issued.
My Worker"COmpevseum Insurure and Policy num a�: a3 J q
CaricrRl2./N2ICATEO PNes.:-WO
T�CERTDgCATE PESArIOIEXEMPTION FROM WORKERS'
COMPENSATI i ftlic RANCE
(Thin ration mod nm becompined ifdie permit it for one hundrtd dollen 15100)
«Icn.1
I certify that in the p me of the wok become
Nis pends is issued.)shall
nes employnmy
mouser
any Canon in nuobecomer sO to bcs.bjat m the worker'Compen-
xtinn lawn of Cdifomi..Dem
Appetite t
NOTICE TO APPLICANT:IC after making this ate of Ex We Cod you a mind
become subject y it WOMB COmpein this eprovisions of se labdr Cade,you muss
fonhwiN comply with such provisionx m this penis shall bo dmmnd revoked.
CONSTRUCTION LENDING AGENCY
O I hereby affirmN"
there is a connmcdon lending agency for the perf,mare of
Z 2 work wk for which Nis Fomris u C.)
issued(Sec.309].Civ.
F,t Lenders Name
a Lmdeis AM.,,,
kT2 1 certify that 1 have mad this upphirdion and nam that the above information is
96 onset.I agree to comply with all city and county ordinances and aam laws relating to
rti z building communion,end hereby authoua rcpemnmivu of this city to emr upon lie
t..) O above-mentionW property for inspection puryaxs.
Lz P (We)agree in save,indemnify and kap harmless the City of Cupertino Against
O U liabilities,judgments,toss and expenses which may in any way accme againn said City
�., rW in consequ<m<of the grand.,of this pared..
[- 0. APPLIL-ANIUNDE NDS AND WILICOMP1.Y WITH ALI.N0Nd4)INT
U z SOURCERF I
Signature of Applicam Comte«« Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the eppliumt or future building mention,stare or handle haaa fous material Re-roofs
m defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Swel, Type Of ROOF
Code,Section 25532(ap '"/' 'J P
❑Yes Qx
Will f applicant or fm.m building«<ap.nt use equipment or devices which All roofs shall be inspected prior to any roofing, material being
crain rudest,airmnumi.an¢aa (N bythe Bay Area Air Quality Mmagemcm installed. If a roof is Installed without first obtaining an inspection
°°"
C:]Yes C]No/ I agree to remove all new materials for inspection. Applicant
is i
Ihave mall Ne M1.,,•dot,marcriala my.lmmrnaunder Christer 6195 of the,Cali- understands and will comply with all non point source regulations.
forma Health&safety Code.Seedimr 25505.25533 and 25534.1 undersand that if the
building dens not cu�Lemlyheveemna Nmltismymspomibilitymn«ify Ne«cupmr
uix�enlFwdeh most prior ret issuance of a Cmifcas of Decuposy.
` I IYLGJ Signature of Applicant Date
aa.e or e.Ntna went Gam
All roof coverings to be Class`B"or better
OFFICE