00020195 CITY-OF CUPERTINO4r- v ' - ' - PERMITNo.
BUILDING DIVISION PERMIT ��C@1,'r GTO[ R I�N�FO MA, I M O..Q�2.b �+
BUILDINGADDRGSS: �5 -J
'L I,,,..,,, ,Anft ri SANITARY NO. APPLICATIONSUBMITTALDATE
7 lJ/ E ( J v/J/t1 J 2-2�-co
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ARCHITECf/F.NGINEF.ER ER / SI ZS B_LDIN. I;LRMIT{I I.
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1... " LICENSED CONTRACTOR'S DECLARATION
I ion? )a That 1 am licensed sands provisions of Cheaper 9(commencing Job Description
with Section 7000)ocDivision 3ofNeBmineecand ProfeuioniCade,and my license is
thhll/orol and affect.
413 E
me. -~�G Con 0.' 'Tt/s'}'�`tII/l O0/.1 �ivW�" N -•(Nys[I ll r'l/�_ VV��+I
O¢ I ARCHI'1'BGTPEELS DECLARATION �.✓' x • ^•""�yV�{ .J%
I understand my piens Mill be used u public records
dHpC
S lAcemeAHnfessiotul
nS: OWNER MIXER DECLARATION
t < 1 hereby.111.that I am exempt from the Contrscm's Lice.«Law for the U
S ❑ following musun.(Section 703 1.5,Buineas and Professions Code:Any city or county
cd.CCC which squires as permit u cmtzuuct,alter,improve,dervolirh,or o pest any structure
$- poor mill issuance.alwouteadie leant for Such rmittoneasi eredvu4ment Sq. Ft. Floor Area Valuation
Jul he is licensed prmintto the ProOm of the Canv tar's License law o0tiper 9
(commcrum,with Section 7")of Division 3 of the Business and Profeuiom Code)or fped Number '
that li is 31.5 b therefrom and the burs for the alleged exempian.Any l violation of 326—J Z� O S Occupancy Type
Scctlon]031.5 by any applicant for a pemdt subjects the applicant to a civil penwty of
not mom then five hundred dollars($500).
❑leesawn«arN property,amy nmin«awithW.gesuthitwlewmpematon. Required Inspections
will do the work,andthe vnuctuse is not intended or oRerd for vale(S«.7044.Business
and Profess u Code:The Consnnor's License law does nes apply to an Owner of
pro'",who bbilds or improvea therm,and who doll Such we&himself or through
his own employees,provided that such impovcmenu art not intended m offered fee
Side,If,however,the,Wilding or improvement is Sold within One year of connIA.d n,the
vol-Wilda will have the Noun of proving But he did nrt Wild Or improve fm pun
pow of sell.).
I,u Owner of the property,am exclusively contracting wish licensed contractors to
comnud the project(Sec.7044,Business and Profusions C:)The Cmartw0ra Li.
clue law doer not apply to ass Omer of p.pmy W W Wilds or impovu shemem,and
wW contrwts for auch penjecu wish a contractor(s)licensed pursunt to the Contnmoe,
License law
01. .0 under Sec. .B RPCforNia
OWner 'One ! /
WORKER'S COMPENSATION DECLARATION
1 tachy aRhm ander penalty repalory ate of the followingreor dischurastWoriers Co
I have and will nuimaineCersi0ce4 of CansenuoselGinaum far Worker's Comps-
nu..,as provided for by Section 3700 of the Labor Cde,for the perf n ence of the s
work for which Nies error is issued.
1 have and will maintain Worker's Compensation Insurance.in rtquird by Section '
3700 ofJe labor Cede,for Nape Ormanee afdC weakfor which thin ptmit is slued.
Cemeorker' oro c Sai Ins.r ce cam Pol Nl ocy numb4ym.� Oq
CERTI ATE OP[XEMPTION FROM WORKERS'�I I
COMPENSATION INSURANCE
(This ssctiormed nes becompletddthi Gamut is faeM hurdrd doll.($100) '
or less.)
I certify that in the performance of the work for which Chir pmul is issued,I Shill" '
not employ any person in any manner an as to become Subject to the Workers'Compen- '
action Laws of COROMia.Dao
Applicant
NOTICE TO APPLICANT:If,after making this Cenificne of Exemption,you Should
become uh*t to the Worker's Compensation provisions of the Lahor Code,yw most
forthwith comply with such provision or Nis permit shall be d«ned revoked. FFEB
CONSTRENDUCTION LING AGENCYI hereby affirm thin them is a construction lending.proy tante performance ofthe work for which this permit is Issued(Sec.309],Civ.C.)fenders Name
> Iender'sAJdren 2 9 2000
A1 certify that 1 have reedNuapplicaion andlute Jut the above inforination is
correct.I agreeto comply with all city and county ordinances and lute laws relating to
Zbuilding construction.and hereby authodrn rcprcsenutives of this city to enter upon theabpeove.mendonsed prorty far inspection purposes.
(We)agree tP save,indemnify and Yee,harmless the City serCupertino.Cpm.
O V Babilities,jdgnenu.ensu and expenses which may in any way accme against Said City
> W in am.segnencc of Use granting of Out annit.
[� a APPLICANT UNDERSTANDS AND WILL COMPLY WIT
SOHALI.NOWP QINT
V
so"Fr, A'DD i'. N
Si WeiollMshli N ouanm Dao
AZA MATERALS DISCLOSURE
e mwrNome building
s
a«pentewp or Candle harallous materiel Re-roofs
u dcfinc0 by Cha Cupertino Municipal Code.Chapter 9.12,end Ne Hedth and Safay
cex,sectinn zss3z(n7 Type of Roof
❑Vas ,�I No
Willtha epPlicant at fumm building«cupant use equipment or devices which All roofs shall be inspected prior to an yy roofing, material being
emit hawdous airconuminanu as defined by the Bay Arca Air Quality Managemcm installed. If a roof is Installed without first obtaining an inspection
°'`" ° I a ree to remove all new materials,for inspection. Applicant
t]Y<s �No g
(have mall Ne havudots MW643 rcquirtmen4 Oda Chape;ti Softbe Call- understands and will comply with all non point sou cc regulations.
fora Health B Safety Cade,Seniors 23505,25533 and 25534.1 understand that if rW
Wilding does nes currently haveatreat.Nu it is my responsibility uselifytheoccspent DD-
oftW u roan hilt mugl be ma pia to ueusnce orfs Cmdica of ufmncy. 'VI
Owneor thoriz • est 1`�f-'�__ 1��°2— Signature o applicant Dat
All roof coverings to be Class"B"or.better
OFFICE