00050085 CITY OF CUPERTINO PERMIT NO,
BUILDING DIVISION PERMIT CONTRACTORdNFORMATION: w6500j)'
BUILDING
�ADDRESS: ..// ���p{,/.y
1 &fo RU'No G1. C.yyp ISrCrI I o SANITARY NO. APPLICATION SUBMITTAL DATE
�WNEWS NAME ! O NIC CONTTROL#�
AN 4 C-C/tv r— L ` 9
F-1
NOV
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ARCHITEC '.NGINF.ER BOLDING PERMIT INFO
o o ca-<( 7773 -zY
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0 lbereb,aRrCIN ;Dam cONTRCgDEARof nCapter9himmnencmg �— Job Description
F==� with S«0on1001y.Olstim.3 of the Bminesa and Professiow Code,and my beau is
in fall force and eR«I.
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ARCHITECTS DECLARATION
l nersamypWnsWlbusedupublie
mcON
u.O OWNER-BUR.DER DECLARATION
(=Z 2 1 hereby affirm Nat 1 am exempt from that Convactofs License taw for the -
Y F o following mason(Section 1031.5,Business and Professions Code:Any city or county
i3$ which revisions a permit to comwct,alar,improve.demolish,or repair any swdme Sq. F Floor Area Valuation
prior its issuance.also mgvims the applicant for such permit m Ne a signed statement
that he is licensed pursuant,.meprov ns of me Conv«tars License Law(Chapter 9 Oa 7 $' QQ(�
(commencing with Section 100D7 of Division 3 of the Business and Professions Code).
mAPN Number Occu aDC T at he is exempt therefrom w th
ata basis far e alleged exemplum MY violation ser P Y YPe
Section 7031.5 by any applicant fora li merit sobjecu the applicantuo a civil penalty of 3 7S Z,. — S
m then Eve Handled dollars00)
(55 .
p msec then
Required Inspections
will dothewOk,and memunure is..imcadedor offend intrinsic(Sec.Wfd.Busioess
and Profeoiom Code:The Convenor'•Lianas law doe,nm apply to an Owner m
property who builds or impo w"thereon.and who does Inch wort himself or through
his own employees,provided that such improvements art nn intended O oR«ed for
We.If,however.the building or improvement is sold within me year Of completion,the
der will haus the lambent of proving that M did not build or improve for
pan-
owner of the property.am ocimise,cmnv«dn8 with licensed comrecwa to
omwct that project(Sec.106x.Business and Profession Codc:)The Convector'Li.
cense law done.,.,,Iy to an owner ofrope
prty w W Wilds m ima pm. thereon,uM
who contracts for such projects with a con ssetonM licenced tt '•
pursuano me Comrscus
License law.
arts axe uma5 .BAPCN this
SIL n OI
Owner Dan
ORKER'SCOMPENSATLON DE CI.ARAnON
137M.I hereby a 9m under penury ofpvjury,nue of the fallowing declarations: C`
]IhaveaMwillm•inWna Cefif teof Con«nuo«ILinwmforwwkee,Compen-
tion,u provided rev by Section 3]00 of the Labor Cade,for the Pafomuonc of the
f
ork for which Nix permit is issued.
1 love and will maintain Wobcrs Compensation Imuran..,u required by Section
the labor Cods,for dr,perfamunce of the work for which this permit is issued.
y Workers Compensation Inguen«carrier and Policy numberoder'. Policy No.:
CERTIFICATE OF EKEMFTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompined if Ne permit is formic hmMred MDers 15100)
Or Ina.)
1 certify that in the performance ofthe work for which this pemtif is issued.)shall
not employ anyper
C
Pa�t u any mnikcr w v m came xubjm m Ne Woken'Cmetem
smiost laws of
Applicant 1 A�
NOTICE TO APPWCA L after making this Certificate of Exemption,you should
become subject m 0th In era Compensation provisions of the Labor Code.you must
foMwim comply wit such provisions or this permit NW be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby am.dust mere is a cmnatmcdon lending agency for the petfmmruee of
.Zi h Ne work for which this permit is issued(See 309],Civ.C.)
Lenders Name
WF` lenders Address
? 1 certify that 1 have mad this application and awthat at me above information is
5 z cometh.l Mon,to comply with all city and county on inam"and sum laws chum,to
U Z Wilds iloccumcdoo.and her.lay,antherien repmmm«ives or this city m enter upon ft
U above-mentioned property for inspection purposes.
W Ea (We)•gem m save.indemnify and k«p humlea,the City of Cupertino against
(� liabilities,julgmenu.costs mMespenns which may in any way acerme agaimo said City
>a R7 inconsequence of the granting of this permit.
[� � APELICAN'1'UNDERSTANDS AND WI LL COMPLY WITH ALL NON-POINT'
SOURGUTA'OONS.
air-2L V 541 v/uw
Srgnamrt of A anUConvactor ayf
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future Wilding Occupant store or Noodle havNous manner Re-roofs
as deemed by the Cupertino Municipal ode,Chapter 9.12.and the Health and Safety Type of Roof
Inde.Section lEly's 15532(11)? YP
Ycx
1 Willthin applicam.,future Wilding«c.pmtumequipmemordevi=which All roofs shall be inspected prior to any roofing material being
coot hawdmm air conuminamx.defined by the Bay Aran Air QWlty Management installed. If a roof is Installed without first obtaining an inspection
6V1C11 ,V I agree to remove all new materials for inspection. Applicant .
Y's
I have seal the Neardon. rdla regmmorent,on&,Chapter 6,95 ofine Gvi- un erstands and will comply with all non point source regulations.
fnmu N«Ith&Satiny Code.Sections 25505.25533 and 25536.I understand Net if the
Wlria H:«e acutrtndy hevcatewnt, smY msponilbility totrotiry Neompant
mf the tswhu ,Poe senpreue«e of a Cenit f cupan y.
�al{dN �ULfiva S/f VLaW Signature of Applicant Date
Ow_
or audum gent ' Data
All roof coverings to be Class"B"or better
OFFICE