00030045 CITY OF CUPERTINO PERMrf NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: y��C . :•.
0 ,U>�el f/f'�✓ F6L JP5 �D• CJ��ht�6 QV
7>g ^^ .(yl �I�• SANITAHYNO. APPLICATION SUBMITTAL DATE
OWNER*SN E: J -4,A) Q7, J5, 6;;Q 46.11 ?'62—C9,21
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ARCIIITECT/ENGINFER NIiIiR BULGING 1'EHhfl'1'INFO P
�G
F. d LICENSED CONTRACTOR'S DECLARATION
L°H? I hereby aRrm Nat T am licensed under provisions of Clapur 9(sorra«Ng Job Description
?y_° withsmmn laoo)aroiviam�s nrNe Bntiaeatma Dnrmro«cMe.wmy ficmteia /�S/�UUaz i/•«� �.F�l [� rI.(/� W/Y✓DOf-�
6 w Q in full facearta eRect. /.
S Lu.g 'ae
o e 'er / cumuss,N — Glf/ /tS� OUT dN� //F/fDC—Je ,
_ °a ARCHITECT'S DECLARATION
r <5 1 undemarid my plans shall he msel u public mxeds Uand Prurmdn"d OWNER-BUILDERDECLARATION bT{,✓T/Zt/ n.)y*a�C(„lf iJfuL '-/-Yl
t-?Vp 775W)EW
I_-Z>' 1 hereby aRren that 1 sm exempt from ate Commtots License Law fw use
3�G following reason.(section]031.3.Business and Pmfminty
ont Code:Any city or cou
w- «q
a which uires a permit m construct.men improdemolish,or re
improve.derepair MY assert
0'3- prim to its ismance.also me,mmislheapplicant for such perndltoriiteasigned suumn, Sq. Ft. Floor Area Valuation
that M is licensed puuumt mtheprovuionsofthe Conmawots License Law(Clespteri) /' 0 �v
Irammmteneing wiamsaaan llllD)nr oivision3artW Baam«a ma Proreetimtcnx)« APN Number OType
that he is emerge therefrom and the basis for the alleged]exemption,Any violation of C' Occupancy Y YP
Section]031.5 by any applicant for.permiuubjccu Bre applicantto to.civil pemWry of —22.....(�V Serio
nes mme Nan f e hundred dollar(5300).
❑ Required Inspections
will do Ne wwk,aM ate structure is cwt immnded oroRered foraale(5x.1016,Business
and Proarty whom Code:The Corover th ra License o do doer n«apply to lf aura gh
proper who builds e:improves thereon,and who does such work himself or through
his own emplayas,provided that such im,rommuenu art nes intended or offered for
sale.If,however,the pudding or improvnmem is sold within one year of compledm,Oro /
pwnams.).will pass da,bu
c rden of pravN[NW at ddidnes « rov
Wild impe fee put,
pose of of sale.).
I,u owner of ct properly,Business
exclusively cootrm ons with licensed mnmmm to
mwm the done
not applEncy
.san owner
of and property
who
Cede:)The Conuerem. nd /
cenxe law das ml apply ie ta owns of pmpcny who s ilds re impruvm cmuse,and
who conluC1 for such pojxu with acontrmta(s)licensed pursuant m Ih<Contractats Q
VW.
Delam a 1
der5 &PC ordii,�r'elas'on O
Owner Due•' µVD
WOR NSATION DECLARATION
i Wreb artier under pmeth or pc jury wme of are follo-xin8 decuntiwn:
❑There end Il maintilneCeniftrme ofConsrpo telfinsurt for Worker's Compem QI
satinn,as pmvi for by Section 3100 of IW IaWr Cade,for Ik performance of use u
wwk for which iF permit is issued.
❑1 have and will mainuin Wor sur s Compensation Insurance.as required by Nation MAR 8 2000
3100 of the UW,Cede,for Be performmce of de,work for which this permit is issued.
My es Compentedian Insurance carrier and Policy number are:
Carver: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 17
COMPENSATION INSURANCE By— _
(This ratiw Dad nes be completed i(IM permit is foro«hundrM ddlers(5100) '�-- -..
By—
or In..)
1 Comfy that in duperfotmanx of the work for which this permit is iMMd,I shall
ma employ any person in easy men«r m inn,became mbjano am Weekes'Comprn-
amon Laws of Califomia Dau
Applicmt
NOTICE TO APPLICANT.If,aper making this Canifeate of Exemption,you should
hccome mbjact to Ne WorYets Compensation provisions of the Labor Cede,you must
fonhwith comply with such provisions or Nis permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
Q I hereby affirm that there is acom action lending agency fortW pMoroanc,of
Z tithe work for which Nit«mmil is issued(sec.3091,Ci,C.)
Undrfs Name
a I Lender's Address
(al I nrufY that I have mad this application and We Nat the above mfomalu m is
Am 12 correct.I agree to comply with all city and county ordinances and sum laws relating to
= Z Wildingconstsuction,sed hereby mWrira representatives of this city to Enter upon Be
V C ahove-mentioned property for inspection purposes.
Lr. F (We)agree to save.indemnify and kap hmmmes tW City of Cupertino against
0 (1 liehilum,judgments,costs and espentes which may in my way socrue against said City
y r` in ronso c«e of gnndago f N s p.is
4 q.ICANfU .RSTANDS AND WILT. MVI WITA ALL NON-MIN'T
SOL 'ER ATION'
s' rt f pplicantlCom Dau
{LVA ATERIALS DISCLOSURE -�
it IMapplicmtorNwreWildingacuymsmrt«handlenawdousmatuiil Re-roofs
m acEned the Cupertino Municipal Cade.Chapter 9.12,Nd the Heilth end Sercty
CType of Roof
Cede.Section ❑ , YP
Will the applirmt or future Wilding occupant use equipment or dances which All roofs shall be inspected prior to any roofing material being
emit mardcua Our contend i �eRand by the Bay Arta An Quality Maram
gemt installed. If a roof is Installed without first obtaining an inspection
DfFri°" / I a ree to remove all new materials for inspection. Applicant .
C]Yes L]No
N.e read n.0,rdaat m.W;ela regairements aMerclapr,6.93 of Ne caii un erstands and will comply with all non point source regulations.
Tania H IN& Y Code.Secti«ts 235(13, J3 233 .I undmund Wt if rhe
Wilding rrrnay tuveatemm.Na" mYrespo icy to notify led acupmt
of the u In
sun pas f milers
Signature of Applicant Date
er or onaedlgen u
All roof coverings to be Class"B"or better
OFFICE