00030198 ( '"CITY.OF CUPERTINO :+ PERMITNO. -
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BUILDING DIVISION PERMIT CONTRACTOR INFORMATION; Olin
OUILDJNG ADDRESS: SANITARY NO I APPLICATION SUBMITTAL DATE
aDOsO rair5Av5kr= ' ata Par? i'%CES
"
OWNER'S AME: a .•., - -.V - -
NIC .-CONT ROL p'
,� 7111 KG Iii' f/ `B J 7�" Deh'��1 ,:Yll,v e ' ' O �✓" '
E� ��� _���� •f l
ARCHITECT/ENGINEER (�R(/�I S� TX 71 c2 ZO IfeL INO PERMIT f0
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`I1 ray LICENSEDCONTRACfORSDECLARATION • 'f
'Z 9 1 bemhy am.that I em licensed under proes
visra of Chep( 9 mamrneming Job,Description ' ,
rL't w with Section 7")of D' n 3 ofmw BusiMssand ProfeuwMCade crap yli«ntt as ♦ s'a
Y$ in fall force and ached
a p rinia.0
License Class Lic.M
w 3 Da¢ Cardiac., 5ipi�G- GdiNdolRJ/DSK , �Aec7Y1�tiT''
Sa•O a ARCHITECTS DECLARATION
understazd an I be used as public rewNs .,
N C Sed fG OMI
BU DER DECLARATION
F r
'Th by citrin that I am attempt from the contractors Loen a I;aw f the
Ofoll g (Section 7031.5.Business and Proniontrus Code Any city or cconty, h a
wh ch rayai Fermat m construct alterimprove,'demd'sh pv any structure, ' Is
pno to it sueher,also balloons rheappl' tf roach permit to flea sgned late m Sq.Ft F16or Wrp 6�a va 3tlon"s 'r-
metheislicensedPursuant to the provisions of Ne Conm.cmer License Law(Chapter 9
• (commencing 'thSection]000)ofDivmim,3o'ut.brnsssand ProfessioMChain)ot s'ApNNumber •' Occupancy Type
Nath s axe pt thfrom and the basis for the alleged exemption Any violation f• O (y /J P Y, YP
5- Sect 7031.5 by y applicant fora parma mbje,ts rhe epPlicani to a crud penalty of 3 DO6
t mora Nan five hundred dollars($5(1
1 azowna oftlC prapeny«my emppoy«r with wages as Ne' m"ampcaissnes, , :Required Inspections
and
do lesions Codec Con rs not License
Law
dos not a(Sa]Oan Buanas
+,and property
Code The rovew fors License law does not apply to amr through of.
.propmy who builds or imdrovu thsuch i and who does such wotk himself of WouBh'his ovinamweseyeu,provided Netsuch..tle sold
arc not iyeofoaoflemd for
•sale If,however.Nh building of pment is at he did not
Wild
in im,now fo the
caner b,Ndtt
will have eo burden of proving that he did not ba'Id _ prove for
•• 'pou of sale) •. t .
a hes owner of dais poepanY am exclusively contracang w W bcenmd ctimemmrs to
maaac(the project(Sen.71344 B ear ad Professions Code)The Contiecmre U. a
'cense Law does not apply to an owner,f property who Wilds or unprovewthereon,and
who contracts for such p I is 'N onarro rf)p ensed Formedroth Contractors
License Law i f a
I sum exempt archers r- B&PCf Nis + G' i -
J ;
Owner ,: Date
. WORKERS COMPENSATION DECLARATION - '�•
Ihembyafiifmunderpe64tyofperju5ywsof"efolicwingdedI.".iu:1 p
❑Inn the and kin far
eCem 37 in fm nu iod n5 inf W kranot pe y, s 1:
sat k, es pro rdhi fol mi Ss is 3]00 of N Labor Code farthepeA w f the
wok( which this Permit issued.
❑1 h and wi Pmmain Worker's Con,madion Insurance as required by Senmri t
39004 Code,fin Ne Pe .finance oftWwmkforwhtchthu1aum,iso mW
ompeMatio cis cat end Policy number me: •-
`PalicYNo.: aa'
CE IM ATE OF EMP110N FROM WORKERS' -
" COMPE SATION INSURANCE -
' (This no need notbr,unplensi if Ne permit is foroMhmidrW dollars olfa)..
r +Iwmfy NCm in my manameafNt wmkfo nnic subject
WomacraC l.hall - .' •'„ '
not employ any person m any manner w az m berme sublem m the Worker Compen
set Laws of California.
ie.Dow ..aa
Applicant -
-NOTICE TO APPLICANT:If,after retic g Nis Certificate of Exemption.you should �+ f . ,• ^ `
batch.mhj&t to the Wcoam'.Compensation previsions of the Labor Cade,you must �t
"fo'nhwiecomply with such provisions ar this peril shallbed«meJ invoked. rF
.e a•.
dCONSTRUCPION LENDING AGENCY '• t /' r
;rOQ - Ih'reby eTom in.tin is.cun5tmeuon lending agency for be perfamunce of _
iii•Z���
the work for whmh Nrs Foot is issued(San.3097,Clv.C.)• t - r•
E:, N Letake.Name _ .. -
a Lendels Address I
_
Wlcmfy doalberveressiffinitip,briamemalmmt tbatth -lm fonw(ion is
A. correct.1 agree to comply with all city and county iinfirmicas and state laws relating to I 1.
W Z building construction,and hereby authorize representatives of this city to enter upon the
°V C) above mentioned property far tmpafion purposes. ^
(We)agree to save indemnify and keep harmless the City of Capitalism ag t' 'I• , ; e
liabl-u espouser,judgments,costs and espses which may in My way,aecroe against said yd City ,
,7, W in consequence of the granting of this Permit 'r .
APPLICANT IiP.RSTSTANDS ANDWILLCOMPLY WITH ALJ.NON'kNT
U. S GOLATIONS.'
SlUgfithim,PfAppheant e5or -,,, '„• t Date
(6'yAZARDOUSMATE IALSOISCLOSURE.
t - WSOtnes.vfi f t wmr
balding part stare or hdl n¢',tidos.mte
arial Re-roofs _
as defined by the Cit err no Municipal C Chapter 9 12.Cad tiHealthmad Safnty I -
Cade,Section 25532(0. - ' Type of Roof i' '
.❑Yes
All roofs shall be inspected prior to.an ' roofing material being '
Will thea brat infamre building occupant use e m mem or dev¢es whmA' , a' LZ
PP 6 W 9 P y
emit hawdous air contiuninenu as defn Bey,Arise Air Quality Managemcm iristalled. If-a'roof ls'mstalled�withouf t�irst obtaining an`mspeetion.
Disvin9' ,t ��
oYe= 'oNo - '� • ,, '_ *I,aggi'ee to remove all new materials for,inspection.'Apppicant -
unders ds`:andwill cora 1 :wlth•allnon .int source regulations.
I hive read the hiumh us materials re irementa under Chapter 6.95 of the Cali. +• ,p Y P , b 1
bra Health&Safety Code,Sections Z5505p 25533 and MWi.1 understand jhm if the•
,;Wilda,chat not currently have a tenank that it is my ie,,.eib'I ytno ifytheoccu
the ?
oOwner
f u.1,which must he met poor to issuance of.C'n'dicmeof Occup. ,•'1` 1, _
a 'or r authorized agent 'Si„ attiofAp (cant Date:
_ Date - re_ t+ \" ♦,
All roof cove Cgs to be Class`+B"onbetter
" OFFICE