00030206 PERMITNO.
CITY OF CUPERTINo CONTRACTOR INFORMATION: `
BUILDING DIVISION - PERMIT
- 11UILD�OQ�OIN S� QQK/�� �• � .L�� ...y �a SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S 8/cT aQE ) + .I msyt 9. LDea L�/UC NIC' �C9NNTROL#
PNON,L: — 596-5 !/V FO •fS -
_ BOLDING I'ERMIT INPO
CHI'fECT/I:NGINF.ER '3 /9
vc/NL J
N irl
ucENsr:DcoNTRAcroasDECLAannor+ Job,Description'
by affirm then 1 am licensed under prov+a+ons of Chapter 9(commeooing 700)ofDiv+sket 3Ofthe BuuwsandRofeaoas Code,ad my licenu+s
andeRen Ela - L+c.#r• Convector /
ARCNITECI'S DP-CLARAnON
�,G S
I �, mtlentaWhall W a ublic 2cads , , -
<f
OWNE B. ER DECLARATION
C z< ' 1 he by aRtm that I exempt from the Contractors License law for the ;" F
Td xF o following reason(Sento 13,Ba+ncas aM Prof ...Code Any city Or ocumy
lo 3 w which 2gurn;a Penn t a oun,.l2r.+mpm.e demolish,m rtpab any I--- Sq.Ft. Floor Area Valuation
pficatoilvisguance,adso uionsthaAPPIiC4rUfor,.h,rrnR.filees+gadateyment .9O SDg/
that he is Ilcead Pursuem m the provisiom of Ne Convacmis L+unaz law(Cluger 9
IcommetaingwiNSadonlgp)ofDivision3afdyBaineaaMPofessiomCde)or APNNumb r - cCupancyType
that he is eaemPt therefram aod the buns for On ellegd eumpti" Any violation of. —O Section by fm a permit wbjecu rW epplicans+o a civil pe+Wty of 40d
at mart,dees flee hundred dollars
g(
Y
asoo:. Required Inspections
I,as mvr+cr of she propcnY•mmy emPloyas with wagesuthcir wle compensado - ,
will tothe wo a Coale:
thesuunu2 is+wtLnddor Law
does out apply to an o umcs. -• .
end Of
coi who Cador inop Contractor',,and w law taus not apply ss il owner gh +his
...who build.or improve thcrtoo,and who tact such t irate Wassail or m through - -
sal own employees,provided that such imptnvemenu are not intended m OBeed for ,
uleIf.howevallhave dingmen of proving
0sold did within yeuofcompinin, the .. °' '
-owner-Wilder will love tie When of provin8 that he did not build or improve for pm-
u
1,
posed scale.). •1' , .�/
° owner of Ne Propcny,en+exdusi convening with licensed contractors t
ohswn the Project(Soc.
Businessand,P (e
Business and, rouiou CW,:)The Connector,U.
/
11.law dace nat.ppiy tO an Own"of propene wW Wilde Or immnvew theuon,end
who contracts for such pmjau wish a contractors)licensed pursuant to the Canv,etota
Limns.law. 0
1 am cacro t antler Sec. ,B d PSC for this 2uon,
Owner ' Date Y ,�
WORKER'S COMPENSATION DECLARATION
I ha26y em...d"Penwy of Krjur5'.M of the r(Enawull declaradau:thorn and will maintain.Cenifi..M of Consenf3o az:6insure fmwori'll"Compem -
anon,a provided for by Section 37W of On IaW,Cade.fm the perfamma of the
ark for which this permit is nOwed
°1 have and will mtinuin Workels Compensation Insurance,as rtyuirtd by Section
39Wof the lad de,for the performance Of the wink for which his permit c.is nucd. .
ISI MY W ampewtio
In
artier Ite,number art:
CER CATEOFE n ON'ROM WORKERS'
COMP ATION INSURANCE.
IThix 2eti n+undfuno ecomple+ediftWpemdt iafmoty hur+Ad dollersl3100) ., ,
or leu.) - '
. _ Mity that in the peEoimenceafthe w'ak for which thin perMt is issued,I shall
Ic
not employ any M'wn inany manner w u to beme coaubjact to the Workers C=Pen- . .
cation Laws of Cold.0 ia.Data - -
APPlicam .. 1'
NOTICE TO APPLICANT,IL after making this Car ifica2 of Ez.mpton,you should ,
III" ho onn mbject to the Workd.Compwuton provisions Of the labor Code.You must ,
forthwith comply wish such provisions",is pem+it shall be damed mvoketl.
CONSTRUCTION LENDING AGENCY
Q 0Ihereby ofbrmshet them m
is.constcdon lendinplocy!Orbe perfamarye of d
the wink fm which this permit is issued(See 3097,Co.C.) -
Isdeks Name
QFt, > Lender's Address
W 1 certify o c 1 have red shit application and .od stem thus the above ws motion it )
L 0 chne=t.I e82e to comply with all city end county dNinances ad city laws 2latin m t - -
U Z W winecmrnedi ioo,arulWrtby.mbodurepresenwiv"OftNs city to enter upon the r ,
V above-(We)rad poo,arty for iospactin Puryp ha - -'
W F ..ju S.to save,indemnify and kap liar in an tlw Cite o Cupertino squirm
C.1 liabilitiu,jdgmenu.cauad npemes whish+nay in any way accrue aBeinst said City a -
�, W in consequence of the grunting of this permit.'
` 0. APPLICA UNDERSTANDS AND WILL COMPLY WITH l.I,NON417)INT
f..) Z SOURCE 'OULATIONS, ,
S' um
2 ofA licantl mnnor
ay'
PP
RDOUSMA NBestoreDISCLOSURE
'Wllthett'l' for fuy2 Wildi necupant anrt or handle hzavdoua m.terial Re-roofs
u defi.d by 1ha C.pr ins Mumci1l de,CWP2r 9.12,erd the Health cad Se/dY Type of Roof
Code,Section 23532(a)T YP
°Yes
Will th,.,,Ll. or future 6 ildiig went.,a an equipment or devices which All roofs shall'be inspected'prior to,any roofing'material being.•
emit heardous air wnumiunuudeand by the Bay lac"Ah Quality Muegamem installed. If a roof is installed'w ithout first obtaining an inspection
48Divi=t, I'aggree to remove all new materials for inspection: Applicant
ilr I°Y`a �- underst ds and will comply with all non point source'regulations.
+I love mad the lurudout maynals 2quirtnxmu order Chapur 6.93 Ofthe Cali- _ '
fmnie sheath&Sefey Cde,Sections 25505,25533 cad 25530.I undmund that if Ne .. ' '
Wi10in8 doeena currtmly Wvee2mmi,dutlt is mY mponaibility ynaify the Occopan - '
Of the 2quitemwu which mut be rrct pnatoissuarce ofaCeniace2Of Occupanry -
i nature of Appli rat Date„
Owner or authonOd agent Data
All roof coverings to'be Class"B"or better
OFFICE `