00090062 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: VIiRMI'I'NO,
OWNER'S NAML. APPLICATION SUIT DA'I E
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PHONE: "' 5 TWIN 91131=P14N
.ANI'rARY NO. (NTROL No
/ ZeARCIIITEC'1'717NGINEER: BUILDING PERMIT INFO
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LICENSED CON'rHACfOR'S DECLARATION Job Description
O Z_CI hereby durst that I tau liacns'snl under pravinia is of Chap,e,9 tcoom.vireng
t..,4L:—� with Somans 9lblll'llDi,kir 3 A lot Bueinces and Pmfcarionv Cadc,atn:yli......
is in full brace; It cu��
z z J Limns ss J]_ Lic.N_ 9a � _.
ow Date 4 00 Craunen,r *,�1C{� * NO CONDITIONS
sisal u�, ARCHITEC17S DECLARATION
F t=N 4 1 undenlund try plain shall be uwd sue public records
de 6O O Llcemed 11roto"ienal
e OWNLI-BUILDER DECLRX
ION n —:n 1 hereby attain,that I nm er amp,fmm the Connixon 1 Limns use In, he
r%'2 following reumn,so tion 90315.Husinc;s and Padcssior%Code:Any city to county
,=a which acquire,o permit m consuuct,after.improve,demolish.or repair any structure
5 p prinand"a node ue.dsorequitenthe ar,licmn crsuchpennit In hluasigmddlermem
that he i.licensed pursuantit)the pmvfsionsofthe Contractor's License law(chapters) Sq. Ft. Floor Area Valuation
(commencing with Scotian lOgp of Division 3 of the business and Profensinn%Code)
or ohm he Is cacntpl lared unt nod he it f:,the it logical rec up 1.Any viol:ulon
of Smdnn 7011.5 by any applicant Il permit subjects the applicant to it civil lanalry
of not more dm11 rive hundred dallnn($5M). APN Number Occupancy Type
❑Las owner of me prupeny,a,troy employees with x.,c,as mdr sole trora,naaborr
win do the work.and the dowdou is not intended our offered for sale(See.IOL!.
Business and Toussaint Cody:the Contractor's License Law cars oat apply In an e L!red Inspections
ower,of pntpcny Who builds or improves thereon,and who does such work hinedif
sir thmngh his own ctnployccs.pmvidcd thin such itupnwctnans:arc not Inmad or
nd
au'ercd Ira rale,u,haw r,me built...,.. tmta to i1 ,,w viount. or NO ASSIGNED INSPECTIONS
asmpledon,the owner-builder will hove the hardener Proving,hut he did not l oilJ or
imrrove for ptupwe of sale.),
❑1 a I the ec r puny a c1 c .iit IY t n ng with licensed moon to
can o f the project(S I(HJ Bol
d l f. nos Cartel TL C raaor'a
t
L len 1 I of anpply t ' of p piny who buildnarrativesthereon
ail h d r her such 1 t inti a siouldereftaos)licit,ad pausluent to the '
Cot.. Lilco,Late
❑Ism csetnpt wdcr Scc. .HBI'C lira this ream
Owner Ute
WORKER'S COMPENSATION DECLARATION
I hereby nflinn under penalty of perjury one of the Inllowing declarations:
l 1 title nn I will anolain a Cathcart of Con's In 1111-masa linWorkers
Compensation, as provided Iur by Section 39(1(1 it the Labor Cale, I'or the
performance of the work fnr which Ihis permit is koard.
.❑1 have and will mainmin Worker's Cotnpcnmion Insurance.as required by Section
3IW of the Labor CWe,our the performance of the work for which this permit is
sued.My__Worker's Compensaio n Insurance carrier and policy ountherr are.
p ,
Cattle, A,I Policy N1.: %J& �p 1—
CERI IFICKI PON OF EXEMPTION PROM WOR KERS'
COMPENSATION INSURANCE
(Phis.section used not he cnmputil if the .to is fnr are hundred dollars '
(S100)or less.)
I ratify thw In the perfornnmen of the work fur which this petit In issued.I
shall 11011mplay airy person in:my arinuer no at ut ncunnc subject to the Waders
Compensation Laws of California.owe .
Applicant
NOTICE l'O APPLICANT:If,alter tWong this Cenifcme of Exemption,you should
Mreamc mna b she lcWalker's Cntnpensation pawmitir,of the Lahr Ode,you..It
Q O follwith comply with such pmvio r,or this scmtit shall be deemed revoked.
4� CONST RUC I ON,LENDI NO AGENCY
aI herehy notion duan them is a aotshuction lending ugoncy to the renemmnce
W of the work for which Ihis pertnin is Issued(Ste,3099.Cis.C.)
S Q Lender's Natne
= 7 Lender's Adders,
V Q t ccnify thw i have read his application and ,are that the above infnrmaicn is
ii [r correct,1 agree uo comply with all city and county unbalances and%lute laws relating
Q V. tobuildingconaructiun,and hereby unthuri,e represannnivesof,his oily In unmripun
all ahnve-nrvnlinnaJ prupcny fur higeetion ptnrywcl.
[�. 4
(We)ague I1 sive,indennil'y and keep hurtNea the City of Cupaninu against '
Vl liabilities,judger t coos and expenses 'ch may in any way acme against said
V 7 City in crnseque cc the gran 11 t aspen
APPLI SITU IDER.T ILL CO IPLYWITH ALL NON-MINT Issued b Date
SOUR U Y'
9.�1�r
sigttaaae sir ;p or a,Gmmr - - r I we Re-roofs
, It DOI15 Tito A.S DISCLOSURE
Will the appticai or fu It hadding ocs coot stare or handle haaam:.a%taatet;:d Type of Roof
us Joined by the Cu ore n Mn icipal Code,Chapter 9.12,and the Health and Safety
CalSection 25532(a19
❑Yes . No All roofs shall be inspected prior to any roofing material being installed.
Will the applicator-,baarc naimtng"vette:tniti%caluiptrentmdeviceswhich If a roof is installed without first obtaining an inspection, I agree to remove
it haramaal tar cnnhatninunt as dclinnl try enc ILty Arm sir Quullly Manngcntcm
aril;! all new materials for inspection. Applicant understands and will comply with
Elyes N, all non-point source regulations.
I have mad the hazardous nuaterials requirements under Chapter 6.95 of the
Califnmin Heath A Safely Code.Seetiam a and 25534.1 underound that
if the bolding Jaen t.that it i< ty responxibitiaymnotify the
accupan,of the req near, sn which s1 met prior o issuance of a Ccnircate 1f
°"'u'dad I Signature of Applicant Date
oxner or samara `e � `Op- All roof coverings to be Class "B"or better
OFFICE