00030114 CITY OF CUPERTINO - PERMIT NO.
BUILDING DIVISION PERMIT 4,6EANTRAGIRIRI gOR P Og RIMATIOg N: �Q 301
BUILDING ADDRESS: t A
�Ivt SANITARY NO. APPLICATION SIIBMnTAL DATE
o oil,- de// tigat--t ► o ti Q. S / '1 3—z3-oJ
OWNrr,���'S NAME: �0, .'g�,A �tp ` NIC CONTROLS
Ko '\ cam•
AldIONZ, j
» ICl J `7 ni.1�4,o,4 t CA �'SV ❑
ARCHITECT/ENGINEER ULDIN(b1;ERMl' NF,Q,
E 0 o Crc$_) 86'7- Co p/ q
0 y; LICENSED CONTRACTOR'S DECLARATION
Z - - '
O _ I hcmbY eRum Nat 1 em licensed and.pmvitirna of Chepser 9(commcreing Job Description
P=t u� wim Session T000)of pivieion3of she Business and Rofeulans Cade.ars my littnu is . r
inNil cenaormeand cRecy_;� �s�. (�
a0 U Liawc Class l Lic.Nt S 1 ,`' ( 1 s1—� 1""u"`^ t�1�t
>_
u 3 a N Date `�f ComraCtXRRATRIN r
a O - ARCHITECTS DEC R{ t �,� p
E y� 1 understars my plans mall be used u public records `SRV.' 1 Tl -h'ho e>
Gf
licensed Professional
u�
OWNER-BUILDER,DECLARATION
I hereby aRirm rbn 1 em exempt from to Contractor's License Law for the
O fallowing reason.(Section 703 1S,Business and Pmfeom.,Code:Any city a county
which rectum a permit so cmrounct.stmt,improve,demnlist,or repair my awnurc S Ft. Floor Area Valuation
prior to its issuance.thus requims me applicant for such paint m file a signed statement Sq.
met be is licensed pos,wnt to me provisions of the Contractors Lianse,Law(Chapter 9 "
(commcaingwith Station 7WO)ofDivision 3ofineBusiness food pmrentiawCode)or APN Number
mat he is exempt Caemm and me basis for me alleged caempmet.Any s'ioWio^of 6 _D O , Occupancy Type
Section'7031.5 by my applicant for a pentdnubjau rte applirans m e civil perelry 0f
rnd moa them five hundred dollars,(SSW).
❑1,as owner of me propcny,mmY pmployeea wim w.gesu meirwle rnmpctuadon, Required Inspections
will dome work.ende:no tumianor Law
1.an u,mineu „
and arty whioms Code:The Contractor's Liana law does trot apply tom awns of
property who builds or improvth,neon,end who dao such work dad ctf a through
for -
his own employers,provided mat cons nnew 6 mon thin not intended a plmon.for
owner,holder evilalso,building hot im of poen u sold thewithiniO one year
Or ins mpledor put.
owner-builds will have me WNcn of posting mss Its did not build or irtpovx for par
WYas Owner_).
C]1. of Be property,em eaclueivelY connecting with licensed conoacton to
oma La d promo(Ser..Oars,Business property
Iso Wi Codei The Coneere
.he law tiers oat apply 10 o awn.of matm(l who buildar ra improves Centra.ars V
Lican 0 Lada for each projass wim eantrecorb)licensed pursuentu NO Contractors "
Lice a Law.
❑lam excmptonder S.. - .B RPCfor this mann _
OwnerDasa -
WORKER'S COMPENSATION DECLARATION `
I hereby inn under Family of perjury ate of the follosving declarations:
I they e andwilloutintaln aCmificamofCo ttoalf.inwmforWorkefaCompen-
tion,are provided for by Session 37M of me Labor Cade,fon me performance of the
work for which les permit is issued.
❑1 hive and will maintain Workers Coepenstamn Insurance,as tortured by Session
3700 of she labor Code,for me performance of ore work for which this permit is isa.M.
MY WarkslCnmpereesion Insurance canis end Policy umbar art: It '.I, V3 \� � •t
Comer: II/Mt._..�
CERTPICATOFE)U114P(TION I�tf Wl0
15
.A'g
COMPHNSAnONINSURANCH {IVII I
1
(This aecdmn need one an completed ifmc permit is faro.hundred dellen(S 100) �l MAR 2 0 2000 u
or las..
1certify that in the of the for which this permit is rlpact.
not employ any person in mymanner aro a to howme subject to the Workes'Compact.
ration laws o(Cali(omia.Data 1 - �-�s
pplicam
NOTICE TO APo the Wo9':If,afar making mit provisions
of of Exemption,arbord You mould Y �.,.,..—�•"«
become a rep to the Worh re Coons orth is proviaiaot of she Labor Code,you man
(oMwim comply wim mcM1 provisions or this pertnh shall be domed corked. ,
CONSTRUCTION LENDING AGENCY
0 Zdark for wh
Q ,NebydHmt shin mete is a construction lending agency for me orfumwue of
.i me ich mu permit is issued(Sar.3(oXI,Civ.C.)
F.,
Under,Name
IandeYI Adcm
O 1 certrtifyify
tr7 that Leve red mixty and county
iunand nam met the above information mining to
(r7y carton,t.gra to comply with y city end county mdtnmces and arum laws relating to
z buildingsaidendi Pro and forcimpationumpseunativee ofthis city thenarupon to
U O above-mentionedp0 arty m.forimanpmcpN. I '
0 U (We)agree b cove,indemnifype and kap hay in an she City or Cupertino against
O in ctsuee,jodeofthe costs and eapenuprot. may in any,wry aameagdon aid City
} CL- in conmquNT N the gmdmg of this penitis.
I• h APPLICANT ULATIOI'ANOSAND WILLCOMPLI•WITH ALL NON-POINT
V SOURCE REGULATIONS. /] �/y(� /y�•
— afurc AFFicanVC ntncter `(/"'•--\ Dam I I • / b
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building acupmt pore or hande Nummus material 'Re-roofs
ar defmed by the Cupertino Municipal Code,Chapter 9.12,and the He"and Safety
Code,Section 25532m)' -/ Type of Roof
❑Yes ANO
Will me applicant or future building Occupant on equipment or&vices which All roofs shall be inspected prior to any roofing material being
cutis herardous aonmouniments d�e(tned by me Bay Ara Air Quality Mmag<mtm
❑Yes '�No installed. If a roof is installed without first obtaining an inspection
" I agree to,remove all new materials for inspection. Applicant
Ihow read tnehumorous a.
tte,aiomentsunderCh. b.95oftheColi un erstands and will comply with all non point source regulations.
fomes Health&Safety Crile Sections 25505,25533 and 25530,I undersand mm if me
building does nes currently basemL Coit is mY scslanuibiliry to notify the occupant `
of th rcauiumeny which m's, me ". suerce ofa Cerldica f0colonsy.
ignature of Applicant Date
nor es, razed agev —�''7-6ase
All roof coverings to be Class"B"or better
OFFICE