The URL can be used to link to this page

00040001 CITY OF CUPERTINO PERMIT No. BUILDING DIVISION PERMIT CONTRACTOR,INFORMATION: t.d t_1 [2BULDING ADDRE.tiS: H —1J3�0 57�2��N(� I�LV� VWj'�GIC/I^Ir� SANITARY NO. APPLICATIONSUBMITTALGATE4-1 NER'S NAM B: o NIC CONTROLM 1 S - 3z3 Fk ARCIIITLLTII?NGINIiIiR 5 BULUING PERMIT INFO O&O �z6U h6a LICENSED CONTRACTOR'S DECLARATION 0 I h.aby ids Nn I am licensed under wrvv m ommep of Clasper 9(cing Job Description „C W wiNs«dan]aoo)oroim.im3ardw BpimaswProreasinpeade.wmrlianp.ia in full fora sand.Bwt. Lima.Cie. Lic.M 3 i H Dere Convacwr ARCHDECrS DECLARATION vo I undersand my plus"I be used u mblic records a%a Licensed Professional OWNER-BUILDER DECLARATION I bcmby.from Nal I un exempt from N.Cons .ea License Lew for the F O following reason.(Salim Tf131.5.Bum.and Prafestiau Cade:My city or county un61 C wltiM mquims a Permit w emuwm,sloo,improve,demolish,Or repur any suuccure ��,,rr�� ? nS Ft. Floor Area /�T Valuaticy e7 3� prior to it.i........Is.means,ted Wixom for such permit w fl.asignedwoctrcns 1'I�w l'(�1 -I 00 QUr)LU Q Nal he is licemed'nuance to Ne provisions of Ne Cmuecrob Licence Law(CM1apter 9 S e mmencingwithSxum]0W)af Division 3.fthe Russian.and PeAasiam Cade)m APN Number Occas Type dust he is emoF,Nuefrum W dre basis for the alleged ex,nptim.Any violation of _Occupancy YP Section]031.5 by any applicant for a'mut subjects the applicant o a civil penalty of not mom Nen rive hundred dollen($500). ❑I,asawt�arN.papmy.come.mpay,rwiNw.gaasNevsol..ampewum, Required Inspections win do professions e work,and the he Com is Iwt lnaended row do fm ale(Sw.]Uaa,Busimu and cu,who code:The Convxtmi License taw dant nm aper lf own,of his we whobuilds m improves,...h and who does such work himself.,amulb ee his own.'ploy the pmcid.1 Nes such impmvc old within art nos immnded a olrewd fm rile.If,Ao der wi Nc Wil ding ren cf, vri is sold , .oney.vofcoaroafor Fed . will have Ne burden exclusively x proving Nat W did nm build ns id conn for pa- poat�i(sele.). cont a own,of the progeny,In m...l and contractingsss with licensed Ccontrarian i- Li- wase dr t.awl apply o an Business and Professions d.or The Cs deem. soul ulnas Lew aces cot amlY to en own.of progeny who Wilda'owl so the Neon,end wW cLow.for ruts pojecu wiN awnuecsm(sl licensed mrtuant w the Conuamofs oLicenselaw. ❑Ism axe undcr5 BkPCfor N' reason Owanrjz� K4 Dam al/ YIN tJ RKER'S COMPENSATION DECLARATION I Wndwslle dm paWty oof Comentofthefollowior dwlueuav: �on, %m o ide i for by n a Certificate7W of Coprnuo Cocaself-,for the amforWcAms Compem worm,as provided for mi Ss issued.3]00 of the Labor Cad.,for the peafomuna of the work fa which ill permit is ioucd. I have end will role,for he doom ma fdoon Immuwhie.h mgnired by Section My Wu va Labor Code,ra N.mance came of she work for which this pennir is issued. Caner: aComp.nrstion Insurance tamerend Policy number tie: Cartier: Policy CERTIFICATE OF EXEMPTION MOM WORKERS' COO MPENSATION INSURANCE (Thio rection need sat WcmnPlered ifN.pemdtisfmmeM1undred doll,n(5100) or las.) I endifY out in she varimmuow mine wmk for which this Permit is issued,l shall not employ enY Person in enY manor as I.Wec'f a._bleu so Ne Woromf Cmnpen- tion laws ofhyfdms^ l rV- /- KP Applicant--fyY+nn A. --MAP ICA :Ir,after making this Cenifcem of Exempion,you should forthwithh,maomuply with so it W ran Compensation provisions of Ne Lebon Code,yon compsuch provisions m Nis permit shill W domed revoked. CONSTRUCTION LENDING AGENCY O O I herby amrm shat Nerc is s ted(S..30 l7.Cvv.agency fonhe pertunppe of 4 Ne work for which this gamut is issued ISa.J09],Civ.CJ t.., Le Name Nu nd a a Iac/r Address W Q I unify Nn 1 have read No y and coup and sum Net tit above w,muting is Odin I agrees to comply with all um and county ntatpneof this sur laws waning e Z abovenQcoptmd anatand y for amM1.darcoses.representatives of this city to some upon the V O above-m.mioad papaw(in ippectian mapper. ks I:w liabilities, .gree to saw,indemnify and k«p hay berin m the City of Camino d City O V inco0es,m.ofmae ."a,Of this swhich cosy in any way stems agaimt s.id City �.r 4r7 in enns.q.ence of the granting of this permit. [- L APPLICANT UNDERSTANDS AND WILL COMPLY WI'TII ALL NONPOINT S(3URCCRIi UTATIONS. I n wyd W-3))4 Signamrc a APPIiomnnm Gore IIA]ARDOUS MATERIALS DISCLOSURE Will Ne amltcont orto--Willing wcupam nae m handle M1acardous amaedel Re-roofs as defined by she Cupertino Munimp. Code.Chapter 9.12,and ds.HmN end Safety Type of Roof Cade.Swtim 25532(.)? / YP ❑Y.s v 1Yul Ne emlicmtarfumrc Wilding ancupent use equipment or devices whim All roofs shall be inspected prior to any roofing material being 1 luardous air conumbunm as defined by the Bey Arca An Qualiey Management installed. If a roof is installed without first obtaining an inspection Zinc, I agree to remove,all new materials for inspection. Applicant ❑Ycs g tLf— Ir Nehvudmsmaterialsrtyuimmenuunder Chaper6.95ofthe Cali. Understands and will omply with all non point source regulations. Safety Code,Sections 25505.25513 and 25714.I understand Nee if the .- rrcml have atpneny Nn it is my mspansibilirymqotiI th occclarm � /2-4o 0 crime wM1i mt)SIW coati isspa.ofa Cut�yn cupewJ I Signature of App ant Dale agcm Dam All root coverings to be Class"B"or better OFFICE CITY OF CUPERTINO PERMIT No. BUILDING DIVISION PERMIT CONTRACTOR,INFORMATION: t.d t_1 [2BULDING ADDRE.tiS: H —1J3�0 57�2��N(� I�LV� VWj'�GIC/I^Ir� SANITARY NO. APPLICATIONSUBMITTALGATE4-1 NER'S NAM B: o NIC CONTROLM 1 S - 3z3 Fk ARCIIITLLTII?NGINIiIiR 5 BULUING PERMIT INFO O&O �z6U h6a LICENSED CONTRACTOR'S DECLARATION 0 I h.aby ids Nn I am licensed under wrvv m ommep of Clasper 9(cing Job Description „C W wiNs«dan]aoo)oroim.im3ardw BpimaswProreasinpeade.wmrlianp.ia in full fora sand.Bwt. Lima.Cie. Lic.M 3 i H Dere Convacwr ARCHDECrS DECLARATION vo I undersand my plus"I be used u mblic records a%a Licensed Professional OWNER-BUILDER DECLARATION I bcmby.from Nal I un exempt from N.Cons .ea License Lew for the F O following reason.(Salim Tf131.5.Bum.and Prafestiau Cade:My city or county un61 C wltiM mquims a Permit w emuwm,sloo,improve,demolish,Or repur any suuccure ��,,rr�� ? nS Ft. Floor Area /�T Valuaticy e7 3� prior to it.i........Is.means,ted Wixom for such permit w fl.asignedwoctrcns 1'I�w l'(�1 -I 00 QUr)LU Q Nal he is licemed'nuance to Ne provisions of Ne Cmuecrob Licence Law(CM1apter 9 S e mmencingwithSxum]0W)af Division 3.fthe Russian.and PeAasiam Cade)m APN Number Occas Type dust he is emoF,Nuefrum W dre basis for the alleged ex,nptim.Any violation of _Occupancy YP Section]031.5 by any applicant for a'mut subjects the applicant o a civil penalty of not mom Nen rive hundred dollen($500). ❑I,asawt�arN.papmy.come.mpay,rwiNw.gaasNevsol..ampewum, Required Inspections win do professions e work,and the he Com is Iwt lnaended row do fm ale(Sw.]Uaa,Busimu and cu,who code:The Convxtmi License taw dant nm aper lf own,of his we whobuilds m improves,...h and who does such work himself.,amulb ee his own.'ploy the pmcid.1 Nes such impmvc old within art nos immnded a olrewd fm rile.If,Ao der wi Nc Wil ding ren cf, vri is sold , .oney.vofcoaroafor Fed . will have Ne burden exclusively x proving Nat W did nm build ns id conn for pa- poat�i(sele.). cont a own,of the progeny,In m...l and contractingsss with licensed Ccontrarian i- Li- wase dr t.awl apply o an Business and Professions d.or The Cs deem. soul ulnas Lew aces cot amlY to en own.of progeny who Wilda'owl so the Neon,end wW cLow.for ruts pojecu wiN awnuecsm(sl licensed mrtuant w the Conuamofs oLicenselaw. ❑Ism axe undcr5 BkPCfor N' reason Owanrjz� K4 Dam al/ YIN tJ RKER'S COMPENSATION DECLARATION I Wndwslle dm paWty oof Comentofthefollowior dwlueuav: �on, %m o ide i for by n a Certificate7W of Coprnuo Cocaself-,for the amforWcAms Compem worm,as provided for mi Ss issued.3]00 of the Labor Cad.,for the peafomuna of the work fa which ill permit is ioucd. I have end will role,for he doom ma fdoon Immuwhie.h mgnired by Section My Wu va Labor Code,ra N.mance came of she work for which this pennir is issued. Caner: aComp.nrstion Insurance tamerend Policy number tie: Cartier: Policy CERTIFICATE OF EXEMPTION MOM WORKERS' COO MPENSATION INSURANCE (Thio rection need sat WcmnPlered ifN.pemdtisfmmeM1undred doll,n(5100) or las.) I endifY out in she varimmuow mine wmk for which this Permit is issued,l shall not employ enY Person in enY manor as I.Wec'f a._bleu so Ne Woromf Cmnpen- tion laws ofhyfdms^ l rV- /- KP Applicant--fyY+nn A. --MAP ICA :Ir,after making this Cenifcem of Exempion,you should forthwithh,maomuply with so it W ran Compensation provisions of Ne Lebon Code,yon compsuch provisions m Nis permit shill W domed revoked. CONSTRUCTION LENDING AGENCY O O I herby amrm shat Nerc is s ted(S..30 l7.Cvv.agency fonhe pertunppe of 4 Ne work for which this gamut is issued ISa.J09],Civ.CJ t.., Le Name Nu nd a a Iac/r Address W Q I unify Nn 1 have read No y and coup and sum Net tit above w,muting is Odin I agrees to comply with all um and county ntatpneof this sur laws waning e Z abovenQcoptmd anatand y for amM1.darcoses.representatives of this city to some upon the V O above-m.mioad papaw(in ippectian mapper. ks I:w liabilities, .gree to saw,indemnify and k«p hay berin m the City of Camino d City O V inco0es,m.ofmae ."a,Of this swhich cosy in any way stems agaimt s.id City �.r 4r7 in enns.q.ence of the granting of this permit. [- L APPLICANT UNDERSTANDS AND WILL COMPLY WI'TII ALL NONPOINT S(3URCCRIi UTATIONS. I n wyd W-3))4 Signamrc a APPIiomnnm Gore IIA]ARDOUS MATERIALS DISCLOSURE Will Ne amltcont orto--Willing wcupam nae m handle M1acardous amaedel Re-roofs as defined by she Cupertino Munimp. Code.Chapter 9.12,and ds.HmN end Safety Type of Roof Cade.Swtim 25532(.)? / YP ❑Y.s v 1Yul Ne emlicmtarfumrc Wilding ancupent use equipment or devices whim All roofs shall be inspected prior to any roofing material being 1 luardous air conumbunm as defined by the Bey Arca An Qualiey Management installed. If a roof is installed without first obtaining an inspection Zinc, I agree to remove,all new materials for inspection. Applicant ❑Ycs g tLf— Ir Nehvudmsmaterialsrtyuimmenuunder Chaper6.95ofthe Cali. Understands and will omply with all non point source regulations. Safety Code,Sections 25505.25513 and 25714.I understand Nee if the .- rrcml have atpneny Nn it is my mspansibilirymqotiI th occclarm � /2-4o 0 crime wM1i mt)SIW coati isspa.ofa Cut�yn cupewJ I Signature of App ant Dale agcm Dam All root coverings to be Class"B"or better OFFICE