00020159 CITY OF CUPERTINO - PERMITNo.
BUILDING DIVISION- t' CONTRACTOR INFORMATION: "
PER
BUILDING 0 O. 2 O.I.�
BUILDINGD qFSS y �! Jj SANII'ARYNO APPLICATION_SUB�M-aITTAL DATE
r OWN17K SNAME: //('O,—•! •` � I8W
sf r •r /Y N/C CONTROL#
l� of 6 29e"��
ARC'lITECI'/IiNGINtiER9' ` - BULDINO PERMIT INFO
I-v= LICENSED CONTRACT'OR'S DECLARATION
llmrcb ,(Seedm,tlemR"nrelued pier9fca.houng - Job Description
Ole-p y under Provisions of Cru �Y '
MF:[_w wid�Sarorand eecOivi9ion3o/Ne I.. -arc Pofncroucode,aM my license is /.� // -� /
ad in full farce and effect. 8 q o,�a,4
m ro Lian4e Clan Lic.M .,
N1,aq� Data—
ae0 L yy
O y 1 unden A Mull be S ECu' ATION j ; /1 S G V
o.p c fc tonal _ .. ., - •J-
u� OWNER—BUILDER DECLARATION
t?a 16crtby.(Seed tha'I 1 5 aempt sub the,Concomofs Lmenx Law for the
E y following rcaxn (Seed-11.70315,to31 tr Buaimr, and Pafnmona Cade Any my w county, 1� -
3 m which n,issuance.
a permit to Coawq,(Sari improve.demolish,or ripair any 9wrnue S Ft._Floor Area'
priormn:ismanx,stx rtgvims the applinmfa a«M1pemula-Rl...igwdmtcmcm t]• �f — Valuation
lathe i9 licensed Wnuant mthepm,ioonsoftmConedetet's License Law(Clupuar9 - l9 n!` O rvO
'(commencing with S.clued 90oo)of Divialon 3 ofine facrea,and profusions Cock).; �(7
the he is eseri dueerram aM the basis for the staged astound".Any viol.tian of AP.N Number Occupancy Type
Section]0316 by any epplicsus for.permit aubj«u Ne applicant to a civil penalty of ���/^+, .•
t mom than five hundred dollars(53(0). -�� W'
Lo .ours,the properly.ar myemPl ormalmhwage9.rm.i(Sm. W,Bust uea, Required Inspections .
will do Profession.
Cade:had she Cortisnot ime.Worawdo, apply
co an Bcm.of
' and my who Code:The Conifer's Li«nx Law las trot apply e su,wrier of
hiso nY who hails:or impales thttan.W who nt a such woh himself or doOl rac
his own employ«s;psudded Nn such improvements m not intended w offered for -
r own"tLhower will h Wilding or impalement isot hediwithin tWildor immo ,fon;the - -
owner-Wilder will have the banded alarming that he did not Wild or impale for pw-
poxofsste.).'
❑I,u mom of the paPerly,not exclusively communist with licensed commsmton to
constacs the projm(Sao 701 Business(Sial Prefeasims Code)The Consr«mfs Li. 1 i '
/z,
cema law does not apply to an owner of papmy who Wilds or improves thereon,and
Who concocts for such pajmts with a concocror(q licensed pursuant to me Contractors �•(Yt/`-•
❑1 rapt under S.
.Bk PCfor Nis
O Dem n x
cr WORKER'S COMPENSATION DF.LT-ARATION -
• I hereby affirm under penalty of pe Jury one of me fol lowing decimation ,earma, -
•• ❑Ihsve Provide fm byneCmi37M of Cement to xlf.infar for Wottam Co.(the
walkr provided fm by Section 3)00 of me Labor Cade,for the pexfomuae of the
wort for which Nis permit is iasuM. '�1,
❑1 have yin will maintain ho Idea Cam,O'da.an Insurance,a his Form by Section
3900 ofdm labor Code,so the performyma of the wort for which this permit is issued. •'
Cm ora OC.Lpgpsa�ficn -y� aecWO P"Icy N..yxA �ut—ls
..n CZZER//TIFlC COMPENSATION INS RAM WORKER$' _ r• � -
- rhms
COEOFEXEMnINSURANCE
(This aatirin madam W completed if the permit is fore.hundred dollen($100)
m C 1z;
las.)
TccrOfy mat in theperfomaae of thewwkfwwhIn thi4permit clumn'Cmerhall
not employe rson in anj'man son W«m nubla,to the wodmn Compc v II{LJ`tr1�E-•lyl t1�CAi'��__a�_"
sauonlaw (Csttfomn-F*q
Aati cant ✓.
NOTICE TO APPLICANT It.a er making cots �f Exe u" u ahoul0
h« (QUIRE
omc subject to the Wm r"Compenxtlon provisions of the labor Cade,you must
forthwith camPly wit such ptavtstans or thu permit Jhall be seceded misted. ,F
CONSTRUCTION LENDING AGENCY
Q 0 (hereby:(feed Ow mart iucaammuwlendingigm,,fo,m inerformams of 1 '
Lenders Name Ich W9 passer 14 issued(SCC.309'!,CIV.C.) r
Landers Name ` t
AI certify than I have read this application and mm that be(Shove isdorrntim is -
z comet I egme so comply wit all city end county orduunces and sum laws m1mas to '
Wilding emman uom road h.mby authorize O,mm ma ives of dustily to mmr upon me
V C) above-mentioned properly fw inapection parpi
'rs (We)agree in save,indemnify and keep huinl s the City j C Peru gain:t - -
0 t.7 liabiliues)Wgmems,cwuerM uprose:which tnYtn my way«ame against said City - r
} L
f+7 ndim of the' mm,of permit t `
V APP CANT UNDERSTANDS AND WTI. MI'LY 'LTH ALL.NON+POIN'T ' 5
SO CEREGULATIU L �y -
U g LV
1 HAZA
onto til W--n ser Dye
RDOUS 'ATERIALS DISCLOSURE
Will theapplieamorfnce building arse t:tore or handle haxardoua mamrisl n
as defined io me Cupmino Municipal Code,CTapttt 9.12,erq me Health aM Safay RC-rOOfs - - -
Code.ovcszsvz(.r. Type of Roof
Will the'm4cant.1 factor Wilding uce.pant see aquipmem o1 davins which All roofs shall be inspected prior to an yy roofing material tieing.
. emit meardaosair`onnmianba•defiled by the Bay Ama Air Quality Management 'installed. If a roof is installed without Pirst obtaining an inspection
Diavin4
❑Yea I agree to remove all new-materials for.inspection. Applicant
Ih.ve read me ha„[dot,comardal,alaimm.nwaeder Chapm,93nfdo esti. understands and will,comply witti'all'"non point source regulations.
(ease Halth&Sefesy code.$mina 2550x,ZSs33 end X.1 understand mat if the
dm cg snacurrent ve a mnan4lhm iii y apo iliry to wsifY the acupant -
of emyuir_to surto' c of ¢am of Occupancy. - -
Owner"r eumorixed age Dem Signature of Applicant Date
C� All roof coverings to be Class"B"or better
u
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OFFICE . ' _