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00050114 CITY OF CUPERTINO _ - PERMITNO. BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: C) O ®S OWNER'ti1I`1.T;`1�HOE: SUIIIqe /k D, c�jy+ ,Yb i HUIhDINGADDRR44 Jx„� SANHARYN( APYLICCATII NS(U�r JB ITTALDATE IOFVt( �-/OC , 1n -� NIC CONTROLX tkc-cgDo ARCHITECDENGINEER / Pa^-� COL. BULDING PERMIT INFO G J CV r F_c.�l ' v ` G1 leo I yzd LICENSED CONTRACrOR'S DECLARATION o z 1 hereby am.Nal i son licensed under pmviiwns of Clupshr 9(comnegammg r Job Descrption �A] Y x C w with SecriceandlO)of Division3of Nc Busi«es a�M fcuiO Cad�e�my littnw is ” rkCµ, .v f -�"� IS�' in full force and cRut. 3 LJC717 rJ IJ gk/aX`-"�^J7 Q/�11�� OVA i O w U Lkin.Clqu Li[.N Coidughom `1 /�/ 5 a F Dere ARCHITECTS ECLARATION / 1 srl�, O g` I understand may plans stud be used ss public rtcmrds �� \re^.S�-Q� X-lMlt V �/4-tYk. VvaY✓-v `ll ac IJcenscd Rofeedional IK=' CANNER-BUILDER DECLARATION V Y a Y, F z 1 hereby. alfimt on 1 u.5 exempt from Na Cuntms CA License Law finite F-O following maw..(Section].L5.Business and ova.do cti CMA:Any city o..my which mgaims.piminm<gnaw«..h<..impm<e.demouN,nrrepair.nr.rw<wr[ Sq. Ft. Floor Area Valuation prior to its immune,also requires the applicmt f«suh permit m ned file a sigsuemem Net he k licenced pusuant m Ne pmvisions of Ne Conmacmta Liamce Law(Chxao9 (commencing with Section 7")of Division 3 ofthe Business god Pwfessiou Code)m N Numb r Ntherefrom and he is exempt therefroand Ne basis for the alleged exemption.Any violation of © D 2_2 P Y'type Suwon 7031.5 by any applicant for a pamut subjects the Applicant to a civil pndry of S _ ecuane powt mNan Bve hvndud dollars(5500). 1.sswtarmrNepwpny.mmyemptoyeeawiNw,gevedeirao1e<ompwtion, Required Inspections will Bothework,anduta heCom ismmineMedmawdos apply ]B As.Business and Pmfudom CMA:The Convacwrs Liarve law docs Iwt apply to w weer of X propany who builds a improve Merton,and who does such work himself or through T 1 Ila own amployaea.pmvidad mm such improvements arc net intended or maerca r« �O\►q� -�a..w.A.r-S E,�C \G� p n�y t We.If,hmveaer,Nc building«improvement is gold withinone yaaaof.hapietion,the 7 I 1 owne'-wilder will hate Ne harden of praying that he did not build or improve for p r- wlm pose M sale,. C I,u goner of Ne properly.em exclusively conaacting with licevsed consume w `-1 rnnsmu<t Ute poJect(Sec.]OW,Businew and Rofessiom Code:)M Cmmumrs V- p e - < Ingo Bas r y w w gout of pmprly wM Wilda or improve m end Q/"w_��—'L� �/ conuacn for such wen pojecu with a conaulor(s)licenved pnuenn to Ne CmnrrComoumrs license law, . 1 ' � x ❑I ren exempt under Su. �/V / (@�— B&P C for Nis rtagon Own« N( ft WORKER'S COMPENSATION DEC MTION I hereby a z m under pnety of perjury one of tie follwing decla io : Iyg Com'have aM will mainWn s Cedifi aw of Consent m wlf-inwm fm Woikda Compn- workf pmvidhi f«by Section 3]00 of the Labor Craig.for the performunm of Ne A , work for which this permit is issued. M ❑1 have and will maintainWorkers Compensation by Section SINE )]WmfNe Labor Code,for the pformnce ofwork for which ms permit is issued. My Wortda Comps satire w«<. br ams Pulicy number arc: Cartier.�.. Policy No.: + CERTIFlCA OF EXEMPTION FROM WORKERS' 1111 COMPENSATION INSURANCE `\�E (This section head n«beCompleted ifthe pram Lis forone hurnmed dollen(SILO) ` J in lead.) U I R E Tani%met in the pAortnenceof Ne work for which do. mm is issued.)shall nmolemployLaw sof alit in wY morn nubjecuo the Wotten'Comps- 1, '� union Laws of Celifomia.Dem NOTIAppliCE sun NOTICE TO APPLICANT:IL after melting this Cmificao of Exemption,you should - buomesubjectyNeWorkers o Compnunis pmvisions bet he lab«Cade,you most foMwiN comply with such provisions«Nis permit ehdl be deemed rtvoked. CONSTRUCTION LENDING AGENCY Q Q Ihereby affirm NU Ncre is•couwcumn lending Ag.my for the Rerromu a z the work for which Nu pumin u issued(Sec.3097,Civ.C.) lander.Name (Y > Lenders Addles A. z I cervi/y Nn 1 have sed Nis application anddune Nat the above sus relating is -777 7 / A. <mnal.l agrte c comply with all city aid county ordNmces and sum laws r upon m � z building consvu[tion,and hereby amhoriu rcpreunwive of this city no cher upon we U C) Above-memimned property roc inspection pmpoces. 2 2 2J ` 5 Ire F. (We)agree a nave,indemnify and keep humled the City of Cu cutum gallant J L. ! ll C U himilitied,judgmems.cuma andexpuea which may in any wvymcmeaganst said City inconcequcncc of Ne,taming mf Nu permit. [� 0. APPLICANT UNIF;RS BANDS AND WILT,COMPLY WITH ALL NON POINT SOURCE REGIILATIONS. uz Slgtuwrt ul'ApplicendComranor oma HAZ..ARDOUS MATERIALS DISCLOSURE Will Ncit'inwror future building occupant store or handle hazardous material Re-roofs u defined by she Cupnino Municipal CMR,Chapter 9.12,and me Health and Safety Type of Roof Coh,Section 25532007 ❑Yea No Will Ne applicamor furw.building necupant nae equipment or devices which All roofs shall be inspected prior to any roofing material being emit haurdouuir comanimms u defined by the Bay Aran AU Quality Mvum geent installed. If a roof is Installed without first obtaining an inspection ° i,.7'] No gg I agree to remove all new materials for inspection. Applicant Yes � lhve mad the huarhws materials comiremem,oder Chapter 6.95 of de Cdi- and a s and ill comply with all non point source regulations. s fads.1 W de&Safety Code.Sec om 25505,25533 and]553X.1 uMvnand that if de ' buildings Icwmmly baw[ F. m.thht it is my rupmibiliry mnctJy the.,am .V-- ofNa me.awhich mussb at odammmwm ofACani5<au MOcculwey. Signatur Ap icl nt Date r or auN ved agent Data 00 All roof coverings to be Class"B"or better OFFICE