00030221 <5po t BUILDING DIIVCIISIONNO CONTRACTOR INFORMATION: PERMrrNo.
PERMIT D
19 8 BUILDINGADDRES$
SANI'I'A YNO. APPLICATION SUBMITTAL DATE
OW Eh. AME:V111 OV)
W ///���
1 11„ ✓,��� I \ NICEl CONTROLx
P 0•�. l -Ifl JCN�sr( �
A tCH LT INEF.R NULDING PERMIT INFO
<zw
'6^ LICENSED CONTRACnOr airra on of CON
O H'p''p I hereby affirm that 1 an licenconsi TDRprovisions of Chapter 9(commenting I Job Description
�m=W in NSecrion]000)of Division3 of NeBmineas and Profrniom Code,and my license is ��� �/, - ✓
Q Y f J 10 fYII forte chit CRe[I. ,v a w
�3'a� unenm cl.as u<.x
Date Contrmmr
u O S ARCHI'rF.CI'S DECLARATION
F 1 und,om nd my plans shall W used u public records
u a o Licerned Prefoo o ull
w^y OWNER-BUILDER DECLARATION
F z I hereby aRrm that I at.ssempt from she Connectors License Law for the
`iO followinus.n
g .(Section]031.5.Business aid fess
Proions Cods:Any city.county
to 3 w which no im:a permit to contract,Other,improve.demolish,or repair my shocwn Sq. Ft. Floor Area Valuation
prim to its i"...aim tec.ires the applicmt fer uch pnmB m file a signed mtemem D 6
Nm be is licensed purmmuo the provisions of the Co...,&.License Law(Chapin 9 (�
mornescrem,ssidiSectim 7Wa)).fDns.krn3coIm1bmunw and Prof..I.Carl.)or APNNumber Occupancy Type
Wt he is escer,t therefrom W use basis for the alleged exemption.My violmon or P Y YP
Secdon]0 L5 by any epplicmt for re permit mbjan the applicant to a civil penalty of 34 alk- a ter p
roam Nmfiveherdteddollars(SSM).
,a<.coma.rthepropertr.eemremplrynawithw.gnsssheumla..npemaanov. Required Inspections
willdo the work,and NesWdum is amt in cadedoroffned formic(Ste.7W,Business
and Professiotu Code:The Contracmri License law does trot apply to an—Or Of
propnY was,builds or improve.thetann,read who don such work N.If of through
his or employees,provided Net such improvements art not intended en o%tend for
asks.If.h.wne[the building.imptwement I.sold within ass your of compinim,the
oxmer-bonder will have the bumen of proving that he did not Wild ear improve f.p.-
paasarwe.).
L u owner of the property,,Business
si and contracting with:)Thor Ceomman'n m
c.La the project(Sec.o an Business and Rofassiona Code)The Contract.'=LI-
who Inco docs nut apply n an owner of pr.prny wbo build,,.,roman thereon,aid
who mntncts for such prolan with a contrnetoKal licensed punuant w die Contra.ors
License law.
❑L em ne r e Date 2 this
owner one
WORKER'S COMPENSAT I TION
1 hcraby affirm under penslry of paj a of the follaving declantiom:
I have am will maintain a Certificate of Consent o If insure for Workers Compo- 0
sm...provided f.by Sado.3700 of Ne Labor Cade.for the perfomwnsce of the
work for which this permit is issued.
1 have most will maintain Wormes Compensation Imurmce,as respilend by Section
3700af the labor Code,far the perfonname of thc weak for which this permit is imed. /
My W.rkn's Compemation lnaurauca conn and Policy number art: Q
Cama, Policy No.: O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This savior road!twt bo compled if the permit is fororchuMrral"Isn(SIM)
.let.)
I certify that in the pafoamance of the work for which into pr mei is issued,)shall
nor employ my presort in my maarcr son to boom,tubjat to the Worker'Conmcm
ration laws of Cid(conia.Date
Applicant
NONCE TO APPLICANT:IL after making this Certificate of EaemPtio.,you should
hien,subjmt to the Worker's Compensation Provisions of the Lab.Code.you must
fonhwith comply wish such provisions or this permit=hall be dammed rcvokod,
CONSTRUCTION LENDING AGENCY
Q Q for
which this et Vert isacomsmcdonleiding agent'fortlu p+fa+nanced
r y the week fee which this prmit is issued(Ste.7097,Civ.CJ
t,. Innders Name
as 5 Larders Address
fL I Gene,Net 1 have reed this application aid sane Net and
suite=iMomwion is
L Q cuildin l agree to comply with all city and cwnty.rdiautiaf and cute laws tclaing to
due
C.7 Q mxOmngcoionedpn,ert bonny crimp,uthessimes mpreunwivn of this city to enter upon dz
R. Febovr(We)a re in Pave for impation putep Worries,
(We)agree b save,indemnify and kap yinn they se or Cupenits against
Q U incoisies,juceofthecoarsnd npenses which may in any way seems against said City
>, 0. Acon.vquenceNDEgrantingor dila pcmi t.
ti � AVPLICAN'f UNDf:RSfANUS AND (IMPLY 'ITN ALL NDNPf INT
V z OURC I I)NS. Ar
I. lice. m4&tur Da 1 �
HAZARDOUS MATERIALS DISCLOSURE
Will de applicant or future Wilding uncup=nt store or handle haaandous tnaturnal Re-roofs
u defied by the Cupertino Municipal Cod=.Chapter 9.12,and the Health and Safety Type of Roof
Coda.Satin.M532(a)] YP
O Ely..
\\ will a ,,licmt 0,future Wilding ,ccupant use e9aipment or devioo which All roofs shall be inspected prior to an roofing material being
it Nuard.us au canwninmu en dA ed by the Bay Arc=A.Quality Management installed. If a roof is Installed without first obtaining an inspection
mwt? /,�(/ I agree to remove all new materials for inspection. Applicant
❑Yes 1, d
Ih.ertsd dr huudw.ma. .tawmienmearattderGbmw695.fNee.li- un erstands and will comply with all non point source regulations.
fomite o Hnith&SafetyCode, s^ 505,M533 and 25534.1 understand that if the
builds orcin' a .Noss; ymsxpo.sihility mnaiYNe. pent
of tis' a of s Cmif �e D Y
3 Signature of Applicant Date
Owns eta r age D'
All roof coverings to be Class"B"or better
OFFICE