00040100 CITY OF CUPERTINOPERMIT NO,
BmI,DING DIVISION PERMIT CONTRACTOR INFORMATION: to / O,O
BUILDING ADDRESS: p�� /
-W65 5CFsd1\ BIrVD OWrJ�iZ SANITARYNO. APPLICAT ONSUBM TTAL DAT
OWNER'S NAME:MA'tIFR'Eib Cry U
NIC CONTROLp
ONE; 9173 g$V0
A,CHl l HC'1'7F:NGINF.ER BULDING PERMIT INFO
Ipu00
EESUG
LICENSED CONTRACTOR'S DECLARATON
z1hereby( mtut1em icodaprovisionsChapter 9(m,nmei T e 1 Job Description
Otpwish700bof Division 3of thmIm.;msand Profw,imm Code,and mYiaMu is
in fail to..old affect. RE " ObF—
z 18< IJceem Clav Co. OL g
W
.;c.LL N DetC P
ARCHITECT'SS DE DECLARATION
I undersand my pWs shall be used u Public recmrds ,
ti a o ticansed Pmf<miorol
sal_'tun OWNER-111211—DER DECLARATION
f-i n 1 hereby (Sect that 1 son exempt from the Cofats-emis License Law for the
F p following manor.(Section 7031.5.Bu,im,and Rafevions Cade:Any city a mainly
C w,dch McInnes a perm;...... ct,alter,improve,demolish,or repair any IWctwe S Ft. FlArea Valuation
3_ Frim tohs;ssunnu,W.rtquitesthe applicant funnelspemul m a
flesimadi...a, y' Floor
tis,he is liaamd p mborm to the provisions of the Ceramics,Limn¢Law(Chapter 9
(commencing wits Section 1000)of Division 3 of dto Busiam said Ptofessiom Cads)in APN Number Occupancy Type
that he is exempt therefrom soul to basis for the alleged exemption.A.,violation of ►r NAP b P Y YP
Section 7031.5 by any rp,Ii.fare 1.1 subjects the applicant to a civil PmWty of d v ?—
not mort dun rive hundred dollars(S500).
„mwnet err VR propeny,amy employs.with wagenm.Wirt ml<mmpematian. Required Inspections
F
l do the work.and the structure is trot intended or offered far'go Sec.7Bf4.Penn....
and Professions Code:The Contractors License law docs hot WPIY Io an owner of
pro,my who builds.improve.Nen int,and wW tiros such weak himself on through
his own cmPle,ons.provided that such improvements eR am intended m.Renal for
We.If,however,thebuildingor improvement ismldwithimome yearofmcfdetion,the -
owner-Wilda will have to,sanders ofprovine Nat W did am Wild or impo.a for par-
pose of role.).
r 11,as owner of Ne Property.sm exclusively confronting with licensed c.tnnors to
m.at to pmjot (Sec. f an Business ropecory wW Wionslds
ds or aThe Contractors Lit
moue law dace not apply je sir owner of progeny robe Wdds a;mprnva rWnnn.ane
who contracts fa such projau with a conuxtodU licensed punuent N to Covwctorn /
L;caaw.
[-] m L /
l am eac SatB&P.C,rorNisrauh
Droner 1L�V Via -�k-a-g /
m3��
WORKER'SWM PENSATION DECLARATIOONN
1 hertbY arm under under porosityof perjury one of the foll.wioe declaruimu:40 O
1'luva mrd will maintvn•Cenlfimm ofCanan.m self-insert for Workers Compere. .^1
nation,as provided for by Section 3700 of the Lawn Cade,for Ne perffs.of the V
work for which this Permit is issued.
❑1 have W will ma;nein Workers Compo.Wien Insurance.ex nquhal by Saxtion
3700of the IaWr Code,for the perfor.of the work for which this permit IS issued.
My WmInnex Compensation Inmrutce cvrim and Policy--main ere'.
Carrier: Policy N..: ,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thin saline need not W completed if Ne permit is forms,hundred dollen(S1110)
or If..)
1 sanity that in de perfomuree of tbe work fm which this permit is inned.I shell
not employ my person in any manner so of to become mbjectto the Wmken'Compen-
sation Lawaar Celiferms.Data
Applicant
NOTICE TO APPLICANT:If,afar making this Certificate of EaemPuon,you ahmld
become subject to on,Workers Compensation provisions of the US Cade,you must
foMwith comply with such Provisions on this Permit hall be domed revoked.
CONSTRUCTION LENDING AGENCY
Z Q Ihereby offnn but Nem is a coniwcuon lending agency for tW perrOmwce or
Z
the
work Dor which this gamut is issued(Sea.3097,Civ.C.) ,
F.. Undies Name
} larder.Addre.v
B7I certify tut 1 have resell Nis application and em,that the eWva information is
am zCann.I agree to comply with di city and county otdbancea and stat,laws Missing to
7i
building...do..bull h<2ay sound.mpraenWives of this city Wmer-pea de
f m) 0 abuvemcnderid property for Inspects.Purposes
Tse F„ (We)agree m save,mummify and kap lura ess the City of Cupertino-guest
U b6iliti<n.jnd8nenu.em,and expenses which may in any way ammeagoirut mid City
} Lu in consequence of she groaning of this pemti.
ti APPLICAN'I'UNDI?RS IANDS AND WILL COMPLY WITH ALL NON-POINT
U Z 50URCp IiGUlAT10Ns. 5"02
0 a 3t+
M IIS 4/l7 �0J
Signature of Applican Dam
HAZARDOUS MATERIALS DISCLOSURE
Willy aplicart Capertn.future Municipal
Co occupant atom.handle hand,es and Saity Re-roofs
v def recd m to Cupertino Municipal Code,Chapter 9.12,and the Hee1N sad Safety Type of Roof
ere,sariet zss3zm)1 YP
' ❑Yea YNo
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
wt assurance air conumbunu a,defoned by the Bay Ana An Quality Management installed. If a roof is installed without first obtaining an inspection
min'? I agree to remove all new materials for inspection. Applicant
❑Yes RAN.
Ile readtWhavrdion, 41mgainmenis ads chapter 695 of Ne Cali- understands and will comply with all non point source regulations.
friends HWN&Safety Code,Sections,25505,33333 and]3534.1 unhntand Net if the
building peas nen currently have a tenant,tut it is my reawnsibiliry an family the mcupmt
_of the M,3 ts whirl t.nor m iasu.ce mf a Cendi nm fg cup-cy.
�-• � 4✓1�(d� Signature of Applicant Date
Owner or earth.zeds en Date
All roof coverings to be Class"Be'or better
OFFICE