00030115 CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:. (7b0 6 ` + S
BUILDING ADDRESS: �p �1 //�� /)
a �20 lJJ -e �V/_Y_f SANITARY NO. APPLICAT ONSUBM TTAL DAI
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ARCHITE i'ENGI.YGER BULDING PERMIT INFO
wooSio> 2 �3 — f�300
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t-N Z LICENSED CONTRACTOR'S DECLARATION
'a° h eby aR m Nu 1 am I¢eved under p o $ions of Chapter 9(comm m ng ////// Job Description
F;C; with Section]000)ofDivision3 of the Buxinur recd ProfNiom Cade.and mY licenx is T/� _UA -
y r-- in hll force and ere
UAL `/ .( �//
p�u LieenaelCla 3 Lic.# o J - !� �!C p /� �/ XY �(/ft•{✓"`^
3 a Dam convector _ /1
ARCHDECI'g DECLARATION [�-� �s n L /Q_xyl
v�r I understand my plans shall be u.cd ar public rccorN CLdd - 5 a.,i- 1 a Vr,Z.2/-//- S
i a o Licensed Pruresubmal >` t�C zsssittJ� 7T
M�; OWNER-BUILDER DECLARATION N—)
E Yz a 1 hereby CRnn Nat 1 am eagmpr from the terim. ss LiAn,c law for the �t,Q `� Z
O following mesa..(Sectim"!031.5,Business W Pm. aiom Cade:Any city s county
prior
t its inti a permit b cross t1he alter,ntrpmva.demolish,or file
e sig any statement
c
5- prionuitsisauance,dsoequimrtheepPlicamforsmhpeamitmBleaaignedsutemrnt Sq./Ft. Floor Area / Valuation
Net he is licensed puauant to Um provisions of de,CurrenciesLicrnx Law(clupaa9 ( 7o L
gummmdngwiN Section]000)of Division Sof Ne Busing••and Prafeuiom Cede)or APN Number Occu ane T e
Nat he is exempt Nvefmm W Ne hair for dx alleged gumption.My violation of P Y YP
Section 7031.5 by any applicant for a permit subjects the q Lica to a civil penalty of L_
not mom Nen Me hundred Lolls.($5001.
p L,arawararthgmaartr.nmrgmlgayaawiNw.guadxvmle=wnanadgn. Require41n ections
will do Ngwwk.Cod Nerwmurc isaor,Lt...
Lawdoe.M appl,1. d,Bwi1of /
and!Pray who b Gado:The over dom Lind w law does nut apply to lf PYner of
hi....who builds or improves Neem,and who does mnM1 woh himself or or through
his own ow sm.
Famished Na such impto said w K nut inmMfc w offered for `�
sale.If,bawev w Us building improvement is coldwithinone ildori prove for m- /
In. chic
o saldn will harc ds burden or proving that k did not Wild or improve for Pur-
pox s sale.). /
I,on,war of 0s Sac.7 y,am exclusively confessions with:)rte, contractor U. D
comtmcr the project(Sec..sun,Business and Professions Ca or i The Cwhirma, nd
Genu law is f not apply tom owner of...a s who builds rs improves ciabra and
who contracts fa such prolecta with acontrmtor(s)licensed pursuant to aha Cantrmmrr
Licensealaw.
0a .
In attempt Sec. .BBPC fa this '
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under parulty,of perjury,ane of the following dalarrhoa:
❑1 haus aM will maintain eCmif37M of the Labor
Code,far for Worker's Compt:ne
uta k f as provided forma Section 3]00 of N<Labor Coda roc the perfomtarae of the
��� yyy k fawhich this Pamir isimice"
pq,l have•Li will oda. Wnrkei•Co co of trim Insurance,h his pcod by Section -
]0W0Q,aW psionsf g�r(uamarcof d woh fa which this permir is iaaued.
C. e < Compcnar c� randy No2ypueNresa^'O �1
Carrier PTIO�Ifiy Na M l33 I ER
CERTIFICATE O OF SATION INN FROM WORKERS'
COMPENSATION INSURANCE
(Thar action need nd becmnPleted ifthc permit is(Drone hundred dollars(5100)
or less.)
I unify than in the my romarce of the work far which this thepermit is Issued.I shall
not employ any person in any me er an n to become mbjecuo the Waren'Coman-
Affillaws of Cdifomia.Due n
Applicant
NOTICE TO APPLICANT:If.after making this
ovisio s of of Exemption,you u coast
brcomc comps o the,Worker Compensationa tisprovisions of the labor Cade.. must
faMwiN comply with such provisions or this permit shell W lamed evoked. '
CONSTRUCTION LENDING AGENCY
O p Ihaelsy union"than,is.commmm.imams agency for the Perfarmmccar
Z 2 Ne work for which this permit is ismed(Scc.3097,Civ.C.)
E., Lenders Name
�a > Leaders Address
fs7 0 I certify that I have read Nia application and sum that the above information is
0. c.t.I ogee to complyimanal with ill city and county mi ncer anus laws etsing.
7 Z Wildingcommuction,and hereby ourhoriu represenmivesifthis city an enter upon Na .
U O .Live-mentioned property for inspection purg oxo.
(We).greem save.indemnify.ad kap bermlgss the City of Cuperinoagainst
O f, luMldea,itdgmrnu.coruand expenxa which may in any way acme against said City
�. Gd in consequence of the granting of this permit.
[-+ IL APPLICANT UNDERSTANDS AND WI LI.COMPLY VO 1'II ALL.NON-POINT
SOUR:, � )NS — �lzo%t�
Sisnatumof Applic dCmaaoor Date
HAZARDOUS MATERIALS DISCLOSURE
Will Ne.plikimm future Wilding ccnupnmaneor handle haaWous materiel fIe_ S
as defined by the Cupertino Municipal Cads,Chapter 9.12.W the Health and Safety Type of Roof
Codc,Section 25532m l? YP Dyer IlaFtfi
Will the applicant or fuurc Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
emit htardous an conumimaru a defined by Ne Bay Arca AG Quality Management installed. If a roof is Installed without first obtaining an inspection
°'"""'
❑Yea 1,3<� I a ree to remove all new materials for inspection. Applicant
I have reed ds haradma mevsiala rryrtiemrnta ander Chapter 695 of the Cah. Un aceta and will comply with all non point source regulations.
forma Health&Safety Code,Sections 25505,25533 and 2553x.1 understand that if Ne
Wilding nuts rely haaamramL Nair to tamapomibiliryumtif tis occupant / n rare ou
fabs nawich moa be tpdorm testaments Otto fff Ips'
� �� Signature Applicant Date
owner or euNoria age - Unto
All roof coverings to be Class"B"or better
OFFICE