00050062 CITY OF CUPERTINO r ,. . g 1
F PERMITNO.
BUILDING DMSION ' .. PERMIT <^ I _-f� l t ..�DD..
•�'
[BUILDING ADDRESS: , : / ,o �� S`'• f' LSAN RY NO.. APPLICATION SUB AL DATE
OFN R'$NA E. :- �/ K 'A ' s IC CONTROL#
I',f G✓�o yr ��r�1 N o S —
50 37 0300 ' c
ARCHITECTENGINEER
U * .
Z O"�'3 n• LICENSED CONTRACTORS DECLARATION = - ., _
v^{ F I hereby aRrm that 1 am Brensed under provs.ons of Chapter 9(commencing i Job Description
HC 0 with Sation]000)ofDivrsion3afthe Bu.nese and Profosiom Cade;and mYli<eriee is - _ 'p `" ('%
in Pon fora and effect G/O O. -
W'T LL y Daknve Criss f( Contnctar o , • '/Y y rte' ' .
!=g.0 HITEC II DECLARATION w `• -�(tea "' I �✓ / O
.1 rode' mY Plans shed be used u public ATION v
oo
a o.o.� Licrnsed Rofeuionel
OWNER BUBDER DECLARATION • r :W I
r 1 hereby eBinn that I am exempt from the Contract .License law for the i
ptoll 'ng tea (Section W31.5.Business and Pro,d nefi Cade My city st county
winch'W perm.m c has the Wer,improve,such
demoWh r rep my structure r'' valuatlOn t-
��m pn to't '. trance also requirtsthe applicant for such pvmit toflee igi.dswtunent Sq.l-,'t. Floor Area - ..
's theih mliunsed pwawmto Ne Proviriana of d.Contrumr Licrnu Law(Chapmr9 '
maminrnmngww sevum]t3W)arrnvia an3arthe Ba.inev.ma Pioeaaidn.CedO.r APN Number " occupancy s.
that he is exempt therefrom and d.basis for the alleged SemnP an.Any vmoduo of Pency ZYP
Second 7031.3 by any.,licmt for.penult subjects te halmliftot R.civil-..try of - �' 'a- -
not more then frve Hundred dollars(3500). -
❑1,as owner of Ne progeny.m my employees with wage u ftirwle compcn.adm,. Required Inspections
wiUdo Ne work,and Ne structure is not intended moffemd!NO nede(See.9014,Business -
rnd Profusions Cde:Th
ae Contractor's License,law tied nm apply towne
o,m r of r
property who builds or improves thereon,"who does such work himself or through
his own employees,provided that Such improvements sec not inlended'or offered for
W..If.howevee the building or improvement ismld withmme,ymn.fc.Watim,the
owntt-Hilder will have the bmtirn of pmvm,that he did not build or improve for Pus -
pose fsale) r „
1 owns of the Property,and schtdvaly marmot,wish licensed contractors ro
cmrnad the p Jed(Sec
livid,Bodoni,add Profession,Cad.:)The Conuuto L n
ce e.Is d stmt apply t -owner f Property ho bonds r item .menton add - - •`'k
who ontrutsfor such proleda wiNacontrecr NU hcenredp rs stem Ne Contra rots s
l
Od
lm exemptunder5a B&PCfor Nlrwon s. '
Own. Data
WORKERS COMPENSATION DECLARATION -
I M1erebY aRirm under Pendry of perjury oiro of the fallowing dedamuou. •, � •- ^ s {J
❑Ihava Pro willrorbyetion37te of GOneem la Code,
far WorkeieCo ofe-
wtion,for
u for by Section 3]00 of the Labor Code,for the peAormena of Ne
work have
which Nis gamut is issued. - u '
❑1 have and will ode,No be perm a Compensation w work
for
h required bisilmeSection r - • „
3700 ftlrc Labor Code,fm the perfonnmce of the wmkfor which Nis permit u'esued.
My Worker's C Bs a Fu m ea c- and Policy miter � 0
Comer. - Policy No'�'Z-(l - '
` .P„C In •CATE OP EMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
(Thiasecfian need nor becompletM ifthe patent is torous hoidred dollars(3100) '•
I ccnify that in the Performantt ofthe work forwhich this Pemot is issued,I shall '
not employ any person in any manner s0 as to become subject to the,Workers' cn
Comp - i s -
wbon laws of cdifomic O.m I - ( • -+ 3 d
t J NOTICE TO APPLICANT.If,after making Nis Certificate of Exemption,You should
become subject to the Workers Compensation provisions of Ne Labor Cade.you mus
forthwith comply with such Provision or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY }a
. QI hereby uRrm Har dram as.cUmtrumon lending agenry for the Perforriwce of - v
A 'the weak for whteH this Permit is issued(Sa.3097,CO,C.)
Fy Lenders Naze - •• f n A
I<ndas Address t .
1 ccnify that I have read Ws appliunm roti tree at the above i manors
•a, ^� correct I.gree m comply w W dl any and county i ccs and stare s miming
r�'z building conawcuon aid hereby amhonu mere .roti aoRhiu city enter upon d¢ -
C.f Q move•memianed progeny for impecdon puryo
W Fy (We)egu wave,in Hy and keg as
the Ciry upenino against
f,J Bebilinu,judgmmts.cosu an expenua whi any way ec eegvnxt Said City, - - S -
�a W, _ ucnce of the gmatin of Nie perm
[� � i PPLI NTUNDEI,TA SANDWI .CO PLYWITM LNON.POINT
y SOUR -REGULA ON.' ..
G i
Sig to of Applicant) m for +Data
H DOUS IALS DISCLOSURE -
dlNeapplic or utum Nildingoeeupamstomormd&ehazudousmamual. Re-roofs ,
. u f ed Dy the Cupe n Municipal Cade,Chapter 9.12,erd the Health aid Safety
Code,Second pd53XAY Type of Roof. - -
[I yea
Will the.ppllrint or futurebuRAing«repent sae a Intent or desires whi=r All roofs'sliall be inspected 'prior to any roofing material being'
emit haurdaus Wconuminants asdefmed b eBay Are Ah Queloy Menal-owan , installed. If a roof is installed.,without first obtaining an inspection
District' - " - I a red, to remove all newfmaferials for Inspection., Applicant'
G � ❑Yea ❑Nd;. . � . gg '
•'understands'and will'comply,With all non:point source regulations.
I have Usual he ms mamdd uiremems Chapter6.95 of the Cali s
f is Health&S ty C dons 35 ,35533 534.1 understand thus if the
bodidl,doesnote nd .tenant, 1 is mYm nsibilby to ONE,the mcuP.( r - x•.
of requirement whi asst met IofaCMifice cu may. 5' ,
.. .,. -.
Signature of Applicant. •," ','-Date ,
' net ar 0a.loriZdl ge
4 °All-roof coverings to:be Class"B"or better
d ... . '.
OFFICE
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