00030033 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING AUDRP.SS' n 1 /_ ra
p�j J G J //I� ` /TnIN�V IN Lj ANITARYNU. API'LICATIONSUBMITTALDAT
OWNI•.R'S NAME: _ /J•rY'TCJ- t' L 1 r �/ !/D / ����
HONE: ^//`� 6- -76�-�/T /yyyr_��,�A NEl
/C CONTROLN
ARCHITECDENGINEHR I{ULDING PERMIT INFO
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LICENSED CONTRACTOR'S DECI.RATION
I hark amm slut 1 w Beamed colder peav;aima ar Gnapar 9 ammeemg Job Description
=E with Sectim T000)ofDivision3of We Busiwn WProfusiov Code yliccmeis
dK in full force W effect
xx O w Licmae Clss Lic.M 1
W 3 l6i y D04 COII4YCwr I1 ,�J`�• ,a.J!I.V,M'- `Ili II��[.%^'A.,.11•�`
s gIr(��rc'�ulwxwno
I undmtW my� diirzaNs
iX w C 13cm.ed Prafcasionil
W OWNER exemptE0.DE CLARATION
7 a 1 hereby e(Sect the 1 am exempt from Ne Contractors Co :Any c law for Mu
s D following uh.a earmotm 70313,Business W nce.de ma Cade:Any city a county
M-s whim its
n e.9.to[cons Me he implore,h panes,,are.sir ed s4unwc Sq. Ft. Floor Area Valuation O J
thea mel tensed edwnquime the inions of for suchpe:maa mfilesmacemtcmerit9
Net he incingwitpStomant to Me of Disionaof NeCBusine s nd ProeLaw tomen Cepla 9 °% Q
thathe I.
(commencing w;thSectionn and M pati,for Me d Buaiesamdent,A.i Com,ft)of w��y APN Number Occupancy Type
Sm he is cumpe ahacfwm W tate.nein for the alleged anemp4an.Any l Prox n o! e P Y YP
am on Men Eve
myapplicationIt fm•pemtit wbjauIha applieannoacivil pemlry of
nd seam Ilan f vee hurdad dollars 15500).
❑Icho ow ark,ane propeuc•mmyemployeea oithwagesnme(Sm.mmpeauiaan. Required Inspections
will dothework,and theaw ture Contractor
Licimdm offereawdefmoraide
pply]014,Meet a
and city who
Cada:The Conor hemi Lienw Law dna nm apply w lf ower gh
he..y who build.or improves t such i and who does such work himself or thrmgh
Na own oweve Me Wildi.G Iha1 such inapeovcmeau art a inamled a offered far
sale.If.hoverer,the Wilding m;mpmvemint iswadwithin t Wild
ofw rove for ane
pwrcr.bcide) will have,ate When of peaving that k did not Wad m improve for pur-
ow araalnz
L an ower of the e 7 an exclusively connecting e .with licensed a anmola to /
mrim act Neproject(See.a are Beirut,Wry-he oro Coae:)The Conlnctola and A�
c cLawdenr suapplyjets warorprolay wW Wildsmiaryro Me Casco V
wW emwe4for ween projects wimaconaswaos(s)licensed Ishmael to Ma Contractors j
LicenL
�'nm exempt candler Sm. .B R P C for this Ieum
Owner Daae
WORKER'S COMPENSATION DECIA"TION v
I hereby affirm Y11dR inmalry of perjury mile of the(Whinving dacha atior4:
1 have and will maintain.Cenificaae or Coment to self-imum far Worker.Compen-
Laine,an provided for by Secure 37W of the Labor Cade,for the performanm of the
work for which thin permit is issued.
1 have W will maintain WorYsis Compensation Insurance.as matured by Section
3700of anc"W1 Code.for the parfonnvse ref aha wast fm which this permit 4 issue.
Workers — Mcoma W Policy
Cardec Z - -T
7/
CERTIFlCATEOFE TION FROM WORKERS'
COMPENSATION INSURANCE
-
(Thus section nead mthmmpleled Rise pezmit is foroehualrN dollars(1100)
or leu.)
1,say that in the perfosan.,sur
.t work for became,
alai.Camp is us'Con shall
not employ of Califon in my menhir w n m berate mbjaa m the Wartcri Connote
-
nation laws of California.Dale
NOTICE
wa
NOTICE hj APPLICANT:If.after making this Cisions or of Exemption,you should
becmaae court to it Wmhds Compensation previsions of anc'abm Code.You must
fmhwith comply wird such provisions or Nis pamil sMll W d«med.evoked.
CONSTRUCFION LENDING AGENCY
I harm,alarmthat Marais a ca i ucdm lending agency fonhe Carfumoace of ._
Z Ne week for which anis p' it is issued(Sm.3091,Civ.C.) r
E„ N Uri Name 1-� ♦� �
ni > Undies Address
kd
O I certify do,1 have rand .pp
this liciumm and sate tura Me above information is �ooO
0. correct.I agree to comply with all city and county ordinances W ataa lawn relating to
D Z building mextsactim,and hamby wtnotire representatives of Nis city roan-'upon the 11'1❑1—'fl MAR S
CJ Q aboveaemioned progeny for inspection purposes,
fi t w (We)agree to save,humanly ly aM keep harmless the City of Cupcnim,gams,
C) U rabitiuesjudgrnaam.cents and expenses which may in my way name against Lid City
��••.s in mmuslumm.fthe Bmatin,of this pe.I,.
'lam d API'LICA ' if%.1 AND WILL COMPLYWOHALLISONMIINT
U Z Signs, II�a tA"I�
,lu d
siemium ofAwR mvAZSRDO Dna ✓�w7Oh-C/GG.!
HAZARDOUS MATERIAL a Dstme or U
Will Ne applicam m
or- uco Wilding occupant or handle hazvdaun material RC-roofs
as defiW by the Ctifmuno Mari Code.Chapar 9.12.W the Health W Safety Type of Roof
Code,Section zss32(a)a YP
❑Yes No
Will the aPPlicant or far.Wilding exapam taw equipment or devices which All roofs shall be inspected prior to any roofing material being
emit harecdoas air conaainen final by the Bay Arca Air Quality Management installed. If a roof is installed without first obtaining an inspection
imet? I a vee to remove all new materials for inspection. Applicant
❑Yes No e
I have rated the huudm,moa .ngairtmma,Meer GLalac 5.93 of ar Cali- understands and will comply with all non point source regulations.
rami.Health&sec ed. don,2 sus.2533)and 25.36.I undersand Mut if the building does nen y t nano, mit is my rte omMilitya the ecapma
of the Iequhamma h I n a.....c af.C � upmCy.
Signature of Applicant Date
Ownermauala011z aBe Oaa
All roof coverings to be Class`B"or better
OFFICE