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00070046 CITY OF CUPERTINO PERMIT NO. BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: © CO BUILDING ADDRESS w Oj//�U�� ' / {�] y]/y SANITARY NO. APPLICATION SUBMITTAL DAT rOWNI1R' NAME � . YJ�/� f l0 ! "•�1/ s�� •r/1 9 (1 � NIC CON9'ROLM 10 NE: r/�s� RCHITECr/ENGINEER _ O /J /�$ J BMIXING PERMIT INTO OKZ �00 nUF F. i LICENSED CONTRACTOR'S DECLARATION Z O 4— I hereby afro Nat 1 am licensed umber puoviume,of Chewer 9(commencing Job Description OZ—O 'j with Smme mand0)of Divii 3ofthe Busimee Na Prokaiom CNe,an my littnse l6 C < Dfull force and cifmt. p Liccme Clan C % Lia.« / u�el u y Dau Convecwr�.l C=O gARCHITECTS DECLARATION 1 v�r 1 undenund my plans uhali to uW u publk recmda /rI1 )1 //�,((j.C� Licensed professional Oat I am exempt fr DECLARATION C Z I hereby alien that 1 1. exempt from Ne Connector's al Licence Law for the z O following n fes aei(Section)o I inu Bmima and Prof ioou Cade:My city s m nty ors �;3 which regnnm.permit m continues,slim.nt for h Mout i,ri e a signed amxms. Sy. Ft. Floor Area - � �Vhtl�latii0 t primaire caned , orequim Neapplicantfor sonpermit License, ssig«d statementChaii9 UV that ing wi pursuant,liveprovisionsNe Burro sUcena Law ICNgerr (eom a it axe withsmtao and)t ro ousfor tho3ofstaged A.,mrCN.)or PN roboccupancy Type Nat he is exempt therefrom and Ne breis for Ne ailegN e..mgion.Any violation of P Y YP Section 7031.5 by any applicant for a permit subjmu the 401cant to a civil penaity Of 3&g- 13-2506 not more Nen Eve hundred dollarr(3500). I,a,rwn.rnrtapraperty.mmremploy«,wiNw.gmaN.ir.a.Gmnpem.tim, Required Inspections will Bothe work,ams the structure is not inteMN mofferN(male(Set 7044.11minea Red Rormuob Code:The ole.de'nc i Liana law soca trot apply to lf owner g his o nY who build,pe improves thsuch end who does each wok deed in or ersouyt W own oweverm,pmddN that wen rent I&sold w thin net intended m offered for We.If, ild"willhbuilding ores of proem iv sold within o«ywo improve fords rvbuilder will love the burden of provin{Nat he did not bulla m improve far For. � pose rf We.l. com to I,u owner of n property..B sin%.am cmt4ecdn{with:)The,C wntnnous i- ����// Li- sea. La the projcn appl(Seey,. )044.wn.,Of and propreperty who Wims,ld, CNe:)Th. .there.n.red whoc law Gee nut apply tc es ownar of pollen who builds or imgo the Neuron,and who contracts for such qoj«n with a conuectm(.)licensed pursuant w the contractors Liana Law. ❑Ism exempt under Sm. .B&PCfor this reawn Owner Data WORKERS COMPENSATION DECLARATION 1 Mnby arm under pemuy of pmjury,one of the following decimation: 1 have and will maimsm•C.nificam FC.'1.alf-insme for wader'v Compen- tion,as provi&d for by Section 3700 of Ne Labor CN.,for the pinks rim M the work for which Nis permit is in ual. 1 neve and will maintain Worker's Compensation Wuunce,as nquuN by Section 3700 of doe labor CNs=y,for,Ibe p erffoorlmorm of the work for which this ImOn is ium/ed. C i Work al//�l` c policy Ib. la'L—I I C —f /1 icy Carrier. W1 C RTIFlCATE OF EKEMFfION FROM WORKERS' COMPENSATION INSURANCE (This amen mea nm be completed tolve pmunk is m.o«nunNN Mi.(5100) or lcsv.) I anify than in the performance of Ne work for which this pemnil is issued,I shall on employ any person in any,maturer a as to become,.him,to thG woken'Cotnp.n- Ration laws of California.Dan Applicant NOTICE TO APPLICANT:if,after,making this Certificate of Eamgion.yen should become,subject to the Woke,CorriMun m provision,of the Labor Cods.you must forthwith comply with such provisions in this permit mill W d«mN mvokN. CONSTRUCTION LENDING AGENCY affirm(] Q I bereby arm Nmm at Nen is a co ' caon lending agency forte performance of Z. Rise wok for which this pcmtit is iauN(Sm.3097.Civ.C.) y F. Lend.ls Name, Ste, > leaders Assns ryI 1 certify that i have read that application sal state that the above information is 0. cooed.I agree to comply with all city and county outhouses and sum laws relating to 7 z building construction,and herby authoda regesenutives of this city to enter upon the V above-mentum l property fm impcction purposes. (L F. (We)age«to ave.indemnify and Imp harmless the City of Cupertino agaimt Q V liabilities.judgments,emu and expenses which may in any way accme against said City >. rg) in cmayu.mc of the gmmvg of this permit. I. 4 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL.NON-POINT L) z SOURCE R EGUTA'DONS. .. Si,..uy ApplicmVComnctor Data �(,/.e_ e9—/0 HAZARDOUS MATERIALS DISCLOSURE WilldaapplicantorfutureWildingmentionstm=orhandleharardou=material Re-roofs as d.fin.d by the Collection Municipal CNG.Chapter 9.12,and the Health moa Safety Type of Roof CNe,Smem 25532(m? YP ❑Ys Wills epplicent or future Wilding occupant ata equipnam or devices which All roofs shall be inspected prior to any roofing material being mit huardom air mmumimnn fiord by tM Bey Arca Av Quality Mana{cnnn' installed. If a roof is Installed without first obtaining an inspection )iamic'F I a ree to remove all new materials for inspection. Applicant ❑Yes No c Ihay.rtaa Ne antaaa,matetala reaniremena rnaer L,ager6.95 afN.e.li- understands and will comply with all non point source regulations. f 1 d (my Ne,Sodom 25505,25533 ant 25534.I uNmmmd[tN1 if the nilding r e� ly havice tamnLthat it is my re,pmsiblliry w mond,the occupant ray n 'he mer pnot w iauasm of a CMlficau of Occupancy. Signature of Applicant Date Ow o .RmixN agent Date All roof coverings to be Class`B"or better OFFICE