00030196 CITY,OF CUPERTINO - "- PERMfr Na.
BUILDING DIVISION l. PERMIT "' CONTRACTOR INFORMATION:
BUILDINGADDRESS: //JJ - "- - •
D /fins —��j/ p� �la SANITARYNO. =.IC=AJ APPLICATION �ITTAL DATE
OWNER' : •N/G/�gfOK� 1. ..1. _
//�� 'M /� L� �en NIC c7 CONTROL(
ARCHITECT/ENGINEER � , 7 6-',2 " BULDINO I'ERMIIINFO
°° SlN4l2 ASSOG -:31a -
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F "
LICENSED CONTRACTOR S DECLARATION -
OZ=a I hereby.IErm thn 1 arts hccnud abler peovrvom of Chsaur 9 fcommeai g .. } Job Description
F,4 C w with Smuon7000)of D'vumn3ofdo BusineumdP fmshuns Cade,a myliunuu
�y5:F� infullfmceaMeRect
to
3 u H Dec a Chu Cc
old mr (//1�i� ,I L •��) /� [��. n
Fu. ARCH DECLARATION - /V/✓IDI/�G_,. 5 Y�INU / /— �� ��
E N i rtutb my s 1 be a public records /
o:�QI
a'n m c Professio `
,. m OWNER-BUB.DE ECLARATION ,}
Z a I hemby a ism thn 1 am uempt rom Ne Comrumrs Liccnu Isco for the -
EF G following... Scelion 7031.5:Business and Professions Code:Any city or county '
s
which rtquho s Permit u construct,Blur,improve,demolish, fit..
..s.,my awnme
a s_ Sq. Ft. Floor Area y�•aValuation
primmstn iensedpoduugai.s the applicant for such mBleasigadship.,9 _ . /® tion
that he is licensed puuumno to pmviaiom of tha Contrulore License Lew(Clupur9 ` (JU
(commencing with Section 9000)of Division 3 of she Burmese end Professions Code)or APN Number - QCCU iNC e
Nan he Is exempt therefrom and the basis for the ellcged exemption.Any violation of " , y, Occupancy Type
t.
Section 7031.5 by any applicant for a pemdt subjects she applicant to a civil penelty of _ ����
pt some than five hada red doll.(S500).
1,ee sane.nrme prncenx car sur employees with w.geamtcir.ole compenmda, "Required Inspections -
willdoNework,aMthe uucluons,is rot menced oroHeml for We(Sm.'l054,Business
and Profusions Code:The Conaacuei Liame,Use does nor apply to an owner of -
propcny who builds or improves shmmn,andwho dose such work himself or drought
his own employees,provided that such improvements art and intended no offered for
• sale.IL however,the building or improvement is sold within nee year ofcompledon,the '
owner builder will hove Use berm of proving that he did not build m improve for par- '
pose of We.). - -
L esowtcr of du proceM,arts exclusively conuuting with licenud tonus..to ;
.sous she project(Sm.70x4,Business and Professional Code)The Contractor's U /
,on.law does nm apply to an owner of proper,who build.or improves thereon.and
who contracts for such projects with a contractors)licensed pursuant to me Conumusell -
License Uw. .. -
0 l not exempt under Sec. .B A,P C for this.uo r
Owner v . Dole
WORKERS COMPENSATION DTCLARATION
I hereby affirm under penalty of Perjury me oftM1 following dI t
M(nissecti.
t] m.as and wdllfor byneCeni 37M of Co emuo elf sal fie a dna Comcec 1
moon as pmvhdhi for mom.
Seetion 3700 or the Lebo Calc forthe performance of the
k for which Nu permit huaaaM
nd will u n Worker's Compensation lnmrance,h uqui�by Sectiond.
,ro.Neperf the wok for which this(enroll is issued. _
persati and P Policy
numb..:
CERTI ATEOF EXE I IROMWORKER$'
COMPENSATION I SURANCE noun YxcomPlesdif the permit is loronchmhd<N doll.(5100) h 4 - )
le less.) '
I employ any Pers n the my ro surhce o as t work for whichthio p e Vocol issued lih n- -
nnialUW any(ells.in my manner so m l0 become mbjGLl la dIC WanktA f`.ampen-
A,liIsws of Celifomia.Dau
cmt
NOTICE TO APPLICANT:If,atom making No Certificate of of Utor Exemption,You should
hecomc subjecttothe Workers Compensation provisions of the doomed
Cade;you most,
forthwith comply with cath provisions m this pennil shell be damrd rtvoked.
CONSTRUCTION LENDING AGENCY t
C 0 (hereby affirm Nat Nem is a concoction lending agency forthe cerrorrhumeof v ,
wZi
be.,it for which this permit is issued(See.3097,Civ.C.) '
y Lenders Name 1
rxxxx
W 1 cenify,due 1 have osd this application and sure that be above information is
d cast.I agrs to comply with ell city and county urditwacs and s laws missing to + _
w7 Z huilding construction,and hereby authoriss rtprtantatives of this city to enter upon the
U C abovx-au Boned property for inspection purposes.
Ls.'F.. (We)agree m save.Indemnify and kap bua mlethe City of Cupertino agvsut .. ,
Q U Iiabilitiee,jud8men ,cmtsaM up swhichmayinanywayoccmesgilnarsud City
;w W mconsequen agrantn8 of this'mad'.
P f INT
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.f,.
'plumaSNS
or Applin UCo4" Das '
Ile
HAZARDOUS MATER A.B DISCLOSURE
Wi11t applicant drfutuabutdin ccupmt Romor Mn ehacmiousmat aI Re-roofs
as dcf fwd the Cupertino Municipal Chapter 9.11,and Ne Health and Safety '
Code.S 9 ..255324)? Type of Roof
❑Yes ON.', -
Will the eDDlicant or future
building
acupmt use equiPmcnlbr devices which All roofs shall be inspected prior to an roofing material being
cmitbacmdoasYuwnwnlvntsaodeEtrcdbyUhLBeyAttest Air QWityManagement ' installed. If a roof is installed without' Irst obtaining an inspection
❑rex d_r I-agree to remove all new materials for inspection. Applicant
Ihave mad do m
herda .
sunalsm{uitemenoM
uer chaps.6.95 of tc Cali- gun rsta and will all non point source regulations.
forma Health&Safety Cade,Sectom 25505,15533 and 1553x.1 und.un0 that
oftheng danwdswhicynotth unanu theno ismyceof a Nlityc.to of the arupant _ e
'cif the rtyuire,nmts which mon be ma pdormissuance ore Ccnilices of Occupancy. �
ign re of Applica Date
Ownercar authorized e8ent '•� '_ Da }
h All roof cc i ngs to ,Class"I crbetter
O ICE