00040049 CITY OF CUPERTINO t PERMITNO. p
BUILDING DIVISION PERMIT .6
- NTRACTO INFORIMA�TI®N':
BUILDINGADDRFSS:
w� /G/�p I V�,yn� ,x �',, SANITARYNO, APT SUBMITTµDATE
cG 6 �A /� (7 (.cam s/•i..vl.c� NIC CONTROL«/•��/(jJ,
PHONC:�� — 7i J4��r D••A_'f� 10 R-5��Z ❑
ARCHITECT/F,NOINF:ER ��� ��/—/�/� ,. IH1L LNG EERMIT INFO
+�+y010Uy
f.�H LICENSED DEsim sdf
'9 y p� I penny.mrtn wt I wCONITtdCTOR'S licensed andm p.viror quem 9(a.mmercmg Job Description '
F=-� wish Secrce swel of D' ion lotthe Bu,imae end Pnf eiotu Code.WmYliunse is //O d .� • n• w/
into../one avd We /•J rc
unnn , �39 Lm."
3 g Dere e'vR r1 Conmcbr �. l. .. av //�.�ge j- •r CZ���kN�C�.i 30 - -Ci(iY
ARCHITECTS DECLARATIO
y-I 1 undentand my Plans sled I bu used as public recmds L{/// _
QO
a.n,c E Li<rnsnd RofeasimW
nS_ OWNEum exempt
DECLARATION
I_S Y a 1 thereby. affirm mt 1 e.S exempt sem the Contractors Co ,Anse Lew for tha 'HJV ✓ ` P3 ,
N F q following Dawn pannus t ]oJL3,Business and improve.
doians Code:Any city or munry
i 3F which rz9uirc,.Penin to camwn,eller,improve,demalim,or np.ir any awctnre S Ft. Floor Area Valuatio)nf-`�
prim'.its issuance,also me.in,the applicant,forsuch pemdtao Ill..&igud,uscnwl /Olu
Net he i,licensed present 0e provisions oftie Contractor's License Law(Chepur9 SOC'
(commencing with Section 7W)of Division 3 ofthe Business and Pfofe„iom Cod.)m APN Nu bar Occupancy Type
that he is exempt therefrom and the basis for the alleged exemption.Any violation of p y yp
section 7031.3 by any apptiaat for a pemN subjects lie applicant to a civil ptulty of 7S 02 .Z
not mon Nan five hundred dol.us(SSW).
❑l.uowneaf Nepropeny.mmyomp.oymwiNwegas as Nair sole compewtian, Required Inspections
will do the wmk,.nd the swcsun is m inrc.dedoroR.red for.1.(Sol.7W.Bushes
and IAofe,uom Code:The Comrutchs Luetue Ins,does nm appon
ow,to an orcr of
property who builds or improves Ihenon,and who does such wok himself as through
his own employes,provided Ihu ouch improvement,are not intended or offered for
o quor,Wav r will have dingthe b r impovem proving
that
wild nom Wild
i r improve
letim,Ne �/ ,
oumer MR.).will harc the burden of proving Net he did not build m improve(or Cur- '
pose.(.elan. e 2
❑h o bwm of ae S..7(x B exclusively cuotrssims with licensed contractors t- O/
comm"!the projem(Sec.]ddd,Business and Profession Calan The ..dome , sed
came I�w coca leach ly o an owner or papeny who Wild..,improves thereon.and
.�1
who ceramic's forsuch pgecn witheconwctw(a).icen,ed punuant to the,Cantrotor', V O
License Law. '
ElIsm exemptunderSec. ,Bk PCfar Nis reas.n
owner Data
WORKER'S COMPENSATION DECLARATION -
• I hereby affirm under penallYaf perjury mu oOW following daWatioru: .
❑1 have and will maintain aCenificate of Conserv to self-ate for Weaker',Compact.
sauna,as provided In,by Section 37W of the labor Code,for the performance of the
Aw k for which this perms isnd issued:
1 have awill maintain Worker',Capmas n
metian Insuruwe, quitai by Section
]W of the tabu,Code,for the pedumunce of the work for whish Nis pnnit is issued.
My Worker's oopetipetion fns artacsnia and Policyn r ;I7
Cemcc�PoliN FROM
J _
RTIFIC OMP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi„ec,imt need not Is,completed lithe permit is morons hundred dollen(3.W) ,
or I u3
Loy any Nein of perforanymanameofthewortfor which this io pennhrkara' grnpe.-
not employ of Canon in any manner so as w Mcone suntan.the Wooten'Compo-
' ration Laws of California.Data
Applicant
NOTICE ub l to due NT:If,after meting this Certificate o of Exemption,you should
Im,'ume subjceuo id Wmtds Compeer thin p.I,elms of the manor Code,you muv
fonhwiN comply with such provisions m this perms Dull be deemed evoked.
CONSTRUCTION LENDING AGENCY
O I hereby affirm the'there is ecunstocdon lending agency for the perfomwee of
y
the work for which this permit is inuW(Sm.3097.Ci,C.)
F Lender's Name
`Lander'¢Addeo
[a7 0 1 anify the I have read Nie application end state that the above information is
Z caned I egee to comply with all city and county card.,and.tam hCs Darting h,
-building conswNon.and hereby authmre
ive presentatives of Nis city to enter upon the
U.O abovamentiored property for impectian purposes.
W P (We)agree to save,indemnify and kap hawlc.a the City of Cuparti.o agelne _ -
O U hantlmea,)ulgaream Cmnaad aspen.Which may In any way accNeegLNt said City
nFr ar (IZI APPLICANTDNI]ERSTANDSANIDWILLCOMPLYWITHALLNON INNNJJJ''' APR 7 2000.
U z SOURCE.Rd, S. �77 v BV
.
Signamrcc.f Appt t/Canasc Data
HAZARDOUS MATERIALS DISCLOSURE _
Will dw applicentorfuture building occupas.t.or handle hmardous materiel Re-roofs
as defined by the Cupertino Municipal Code,Chapter 9.11,and the HW N and Safely
Cade,secca.M531(07 Type of Roof
❑Yes
Will thaepphantort9ome WiMngocc.pantas.ceuipoentordcviceswhich All roofs shall be inspected prior to any roofing material being
cost Insouciant an conuunimnts as defined by the Bey Area Air Quality Management installed. If a roof is installed without first obtaining an inspection
°`"" '
❑Yen I agree to remove all new materials for inspection. Applicant
�,
I have Dad the haouda,maerlals raponaoents under Chapter 6,95 a the,Cali. und erst n and will comply with all non point source regulations.
tomo Htalth&Safely Cade,Sections 25505.25533 and 75534.I understand that if Ne • /;/
building does c ave.ten Ihatit is my mapoasinlay a notify toe pant
of th.re,ry' ,wMe must be poor to iasona of a Cenific.¢ D U
Signature f Applicant Date
Owoer or euthon agent due� '
All roof coverings to be Class"B”or better
OFFICE