00020076 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
00<22- 00
-71
O
o BUILDINGADDRESS:
�L�D PDLl-iso /pf` . SANI'1'ARYNO. APPLICATION SUBMITTAL DAT
OWNER'S NAME. Y✓ W.etY+:aa PC)RDX C�6 CJI L lO CSO 00
R A02 POL I !} (,1T 95001 "/c CONTROI.p
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BULDINGI'IIRMI'1'INFO
ARCHITCC /ENGINEER /X p.yt N' / ��g w G
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LICENSED CONTRACfkrp DECLARATION
O Off= :hneby aRtm mat l un IicrnsM unser provi.io ra of Chapter 9(ronnme«ing Job Description
ozrn wi'111
S«Jon71 )ofDivision f mii ..ddP7m�kuionr calc,Wmyhoossis n mow,/
<y 5 in full'wce and (� I J r 6!� jr-m7 ,,Y %1.(saw')fa
d U License Claa
It,N
D Cono-scmry.+� �•
a 0 3 wRCHTIECTS DECLAfuRON k� I✓G kw CQ/✓p✓I r
1 understand my plans shill be used u public words . /J ,y 1 �1
Licmmd Fmf.Wm9 /� rJ/j�C /t �/V Lr l/v
m^ OWNER-BUILDER DECLARATION 4F
I-z< I bcrtby anon mat I an exempt from the Conrado',License Law for the
g F p following ratio,.(Section 7031.5.Basi r ss and!Professions Cade:Any city«wunry
C m wMN rtquisc a pemnh m comw0.al¢r,improve,demoli.h,or mpur say awenve S FL Floor Area Valuation
3_ primo,iuissuate,als oporesthe,mplicamfors«hpemul.Ft,.iigordatammem y'
met he is licensed paaum m the pmvisions of the Conaacmra Liesme law(Chip's,9
(co he is agwith Sec Tics.and
the,of pati.for themcited c.evodon A.vi Codn of APN`umbos,o occupancy Type
or
Jut Inc is essmpt therefrom aM the buffs for me rlegcd exemption.AnY violuion of O
Section 7031.5 by my applicant for a permit Weim"the aPPlicmt to a civil penalty of
nmmon om JEve hurdred dollar own.
°Let..,of am gognY,or my employees.his i for We(Sole compensation.i,n. ed Inspections
anddomewok,ands:Taucareisnots Licensorawdofm Wapply(Selto 40.move,
and Rofmhio Code:TW Cmaacmr.License law does nor apply to If owls or
property who builds or lotions..it thereon,ask who d«r m. wads reimulf or through
Ws own employees,provided r i such improvements is assenu me nor inmMN ar offered for
We.ILhowever thebuildingmimprovement isoldwithinoa LId r,mm f,n,the
wit Wilder will have then,o n of pmviel mal he eid not Wlic or improve nc pus-
poseof WeJ.
cl 1,u-wtr of arc p..7O4 on roes si and confuting Code:)
oh:iThmd comtadma t.- D/
consfud d es.1 apply
7040.Bmitss and Professionds-1 rover Conf«toms nal
whoc law ata set applyje ts ow.of prosproorY wW Was or innptovu thereon,ark O
who contracts for such projects with a confmmmr licensed puruenuo me C-nfumms I�
IAcmse tion.
❑Ions exemq uMerS«. .BKPG fa this teaunlot "
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of erjoy of of the following d«laratimar
°1 My<nk will maintains certificate,of C.—I in selGlomire f a Wmon"Compen-
W inn,as govidW for by S«tion 37W of lie Labor Code,for the performance of the
^^�3work for which this permit is noted,
i/ °1 have and will maintain Worker's C-mpenatlon Insuraue.u ro ni mcd by Section
37W of Ibe Wr Code,for the performance oft work for whitthis pcomiI is sale _
My Work, pe aI In .nee carri«sed polla=qD
Comer. policy No..
CE 'IFlCA COF OMPENSATION
N FROM WORKERS)
COMPENSATIONsKorn INSURANCE -1
(Thit mcunn noes nm be eomplemarcthe petmhi.for h-cede ata(ilW) _
«len.1 I
Ioy my posom he in.,crmmmeofOmwmkfm odjec,thispermitwoisissucompm- fr'^ opo
no employ any penon in my manner so a to become aabjeeuo the W,rken'Compeer-
nation laws of California.Dam s
Applicant
NOTICE TObi APPLICANT:IL after making this Certificate m of Labor on,you abound \\ C
foorwi ,comply
y Jan Wmkc/a Comte or this provisions of a e Labor Cade,You run
forthwith<nmply wins Hoch pmvisions m this pctmlo shell b<deemed revoked.
CONSTRUCTION LENDING AGENCY
O 0I hereby affirmthis them isaconsweJon lending agency for the petfomunce of s
Z Ju work for which this permit is iutd(Sea 3097,Cie C.)
Lenders Name
(� 7 Ia�Mcr'.Address
W I eerily thu I have read dors application and ante that Rhe above infomtaaon is
6 comm,l agme to comply with all city and coumy mdmants,and state laws relating m
7 Z Wilding can,fucan.and herbymmmire rcpremmoles-(this city to mom upon the
f..) above-mentioned proem,for inspection purposes.
4aa (✓ (We)time ro save,indemnify and keep hairless the City of Cupertino against
O I.7 liabilities
.jWgamnu.cronies,c.,.a which may in my is,acemeagmmt said City
Wo is consequence of the goring of this permit.
't• 0. APVLICANr . Uli ANII ND WI LL COMP Y WI'1'H At.],NON.I'OINT
V z SOURC81 .0.IA ONS
Signature:of ApplicanWonfactor
HAZARDOUS MATERIALS DISCLOSURE
Will themli,emor to.Wiking tcupant It—or handle hauNous mammal Re-roofs
as defined by the Cupcnim Municipal Code,Chapsrr 9.12,tad the,Herm aha Safety Type Of Roof
Code,Solon V553uan yP
ffr.. ON.
Will da,meicasoor fuarc Wilding acupend U.equipment or devices which All roofs shall be inspected prior to any roofing material being
-mil huamd-u.atrconuminants as defined by the Be,Ansa Air Qaliryan
Management installed. If a roof is installed without first obtaining an inspection
fico] I agree to remove all new materials for inspection. Applicant
1,�" °N- understands and will comply with all non point source regulations.
0 Adoo
have arardoue mamma muryirtmenta uMer Chapter 6,95 stof am Cris
HealthCode arta 35505. 23534.I utkvatanE Jut if this
p carcnmo, nismYt .thnnp oa edifice, fOlcti'ma. Signature of Applicant Date
m Dam
All roof coverings to be Class"B"or better
OFFICE
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