00030203 ` CITY OF CUPERTINO f PERMITNO.
BUILDING DrvISION . PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS: a��
a0/QO klktr LAI. Wd ra W .
4il1,Dias/, /nC SANITARYNO. APPLICATION SUBMITTAL DATE
OWNER'.NAME: r'WW G _ l�C^l R "L K, -rtfa' 3 ,
ILrmq�g O� y/���/�J/ /i�Q y/� NIC CONTBOLI
VGA/"f'I � ��ILC
6sa - sq -saoo 0a ll�s
AHCIIIT[CI'/tiNGINEER
BUTA 'rP
INC CRMIT INFO
�:� s�Nzr�re Assoc 2i f- 3 Via,- -3 ,1.�
<G
LICENSED CONTRACTOR'S DECLARATION
O i„, I hereby affirm that I un licensed under powitions of Chapter 9(entrance g Job Description
p u;(_ with Section 7”)of Division 3 ofthe tramew and Rofeuiou Code,uJmy&cnse is " '^
m ful forceand effect.
O O
License ClassLic.M u
.w 3,w y Data Conumtor .• ,'f '.1 /�/� //`/lty��'
h a D0 "ARMH�SARCHITECTS DECLARATON - R(, QDING W IAJ007 / a� K 2�zq eewcIv rax li cadsd.lE WNERBk� DFj ARATION
at 1 am y(ey t f 1Q Ne ConuttroY L<e re Lew for the
G n]0115(-0 inns and Rofailma Cade A y eo or warty construct Jmr i prove dcmolah r rep y coumme ,
petal a.t Jaorry.tnxthe ap❑h<.ntraa.<npemuO tee. grcdtastfin '
ent ,'Sq. F[ Hotel-Area-, oO'S�tiofi,.
Nat M1e u Lensed Wmannu the provaioa of dre Contractors Lt...Uw(C'hapsm 9 7
(commencing with Secdon]000)of Division J of rhe Businna and Pm',aionaCnde)or
wt he it exempt tharrmm me do bun for the J1egnd«emptirn.Ater violarea of APN Number Occupancy Type .
Section]031.3 by mY epplicmt fa.pcmdt sobjeca the applicanuo i civil penalty of /
W'
mon thin five h usitW dollars($500). 36
`D as owner of Ne propmy,mmy, cmployoe,wish w.,n as Nevso1e emnNumirs. Required.will do the work and theranneu a is no amended or offend for We(Sm.7W,Busrress Inspections
and Pmfeuiou Cade:The Consucmr'c License Law does not apply to an owner of 'r
;propcny who builds m unarovet thneon,and who does such tion himself or Womulla
his own emPloyees,provided thac such impmvrmena are not in-'nded m offeror far 'sale.If,however thehuildma or impnwemem iamldwithinoneyearofcompletion,the t '
owrcnboilder will have the Wadden of Proving that her did not build or improve for pm- -
.pose.(We.),
I]I,as owner of the property.mar exclusively contracting with licensed contractors'. •,
onswct the
Most
ISec.]OM,Business.nd Profeulom Cnde:)The Conbncmr'a LL - '
ase law does no's
m an own'.o/propmy wed builds er improver d-'non,and i
wh.romrectx forauch projects with a contnda(q licensed punuenl to the Conha<to(a
License law. •
❑l am examptundersoe. ,B@PCforthisnas°n
Owner' r Dare
WORKERS COMPENSATION DECLARATION
i hcnby efRrm under Pt Jly of pe Jury one of the following decl i imu:
MR ❑en..1 red idl for
oulan 311 of 11 L.Wo Wf,fan( Work hCe of,, VVV
ration,r presided for mi Secy n 3]00 or Ne Labor Cade.fa the performance of the
otic for which this petrolis .ed. � I -
❑1 have and wt lout,Wortelx Compensation Insurance.tsngvired by SMIOrI -
3]00 nda,for the a work for which this permit is lamed. -
o pe ati° ce con ' d Poll number sn:
CERTI ATEOF PDON ROMWORKERS'
r COMPENSATION INS HANCE '--f
//## E; f
(This recunrs�rg not be completed ifdu, lisfororchundrtJdollan(51W)or loss.)
I certify that in the performance cf s workf.r'whieh this permit is Von I shall
no
Worn
I-aw,any person in any menrcr m ax b become aubjxl w dr else.,Cooper. -
sdo r
e n Isco
.of
CJi(omia.Dan
Applicator
NMCE TO APPLICANT:IL stn noticing this Cenifican of Earmpdm,you should
( become subject to the Weekes Compensation provisions o
P< ns f da Labor
Torthwilh cam I P Code,You most .,
P Y with corn provhiom or Ws permit shall be decmed nv.kW.
CONSTRUC HYS LENDING AGENCY,
_
Q lhercby affirm thutMmisac.nswcdon lending agency nor the performance of -t ' -
H ti the work for which this permit is issued(Sec.309],Civ.C.)
I<ndres Name s'
Oa. m� I mlces Address
1 Q' I certify thm 1 neve read Nis apPlicnion and rate NJ Ne above iofmanntian is
V WZ CO7 l I agree to comply with ell city and county ordinances and sate laws¢luting to
W7
conauucdon,anal hereby audwrire rtpserentelivea.fIN,city'.antro upon the
_0 ebovemrntionedproprny for unaware purposes. _
tam F.m (We)agree 0 nave,indemnify and keep harmless the City of Cupertino.'rinst ('
lirbililirr,jutlgmems,rovaendexpcnsev Which—liemyweYaatu=agmnsluid City a
in ronsequeoee of th<gmnung of th'a oelna .• `
APP 'ANTU ' ?RSfANDSA WITH AI.I,NON-POINT
V IRCI R', IATIONS.
Sig Isnot A,pbcmVCon a✓ Dm=
BAZAR MATERIALS CLOSURE `
Will theeppLcumafmmentildngoecupen slmcerhanmhaa.r,h m-' I Re-roofs
r, u def rrcd by the C.,mro Mumcmpal Cndc,Chapter 9. do Health and Safety -
ere,tenon sssu(n] ".n1 Type of Roof
❑ties kt� a
Will the appincmt or future building occupant use equipmentatdvices which All roofs shall'be inspected prior-to any roofing,material being
m'"a °°°ar'r=°^ ^' a and=f^= err •Aham Mjn.g=m tet installed:If a roof is installed without first obtaining an inspection
Diming
❑Y ' o o I agree to remove all new materials for inspection. Applicant
a.enadth ar,;da,anatewart,.;nmmuo derC,apter695ofdeCe. un erst ds and.will eom ly with all on point source regulations.
trema Hmlm&WVY Cade.Sectiorm 25505,35533 and 255],1.1 undervmtd that if the - - -
buildingdoesteacurremlyus"o--'earn that it is my nspomibdiry mnoify
of the revuhmma widen must be,met prim t.wuarce of
Ccmfrcme of Oce. y.
57;_oramb.nam.6ent Sig acre of App ' ant Date
' Y' AII-to of c era Ss to be Class"B"or better r
a
OFFICE