00040177 CITY OF CUPERTINOPERMrr NO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: Qg-OLt 0 ) r,
1 BUILDINGADDRFSS:
SANITARY NO. APPLICATION SUBMITTAL OAT
V 111 W
J NER'S NAME:�;IA -NIC CONTROL#
PHGN;:: , ID�t 13. �rNe fay. ❑
Milk
ICHI I'ECT/ENGINEER ul1LDING PERM[IINTO
ec
r LICENSED CONIRACfOR'S DECLARATION
O vi- I hertby affirm Nal 1 am licertsed under provisiom of Chaper 9(mmmeaiy Job Description
y1-w wish Section)000)ofDivisionJofNeBmincu and Profcssiom Calc.and my littn.is
ac i in full fore[and r1
:eau a«n - ` e - Lic.g O�aV n.'�d21 / 9A'1�rJ.t^S
3 w y Deee Convector
ARCHITECTS DECLARATION
'RaIunlemandl my plans shell be used as public randsFA,rN4� r
ao a«need Proreumml ;k.5eaIt FAce aBsI. CtP CAri. Lig�.s't'/^j.
seri-' OWNER.BUH.DER DECLARATION
s-z r 1 harby aRrm Net 1 sum exempt from Nu Commumes License law for the
H o fowi
llong reason.(Secti78
on 31.5.Busiast and Professions Code:Any city or money
which mluirts a Furors N[""°"``.lees'improve'drmardiah,or repair any svucmrc Sq. Ft. Floor Area Valuation
prior to its issuance,also remains,the applicant fa such permit w File.signed mt[ment
that he is licensed pursuant to the provisions of the,Com more,License Law(CImpur9 J✓O
(commencing wish Section 7")of Division 3 of the Business and Pmfaaiona Code)or ane APN N tuber Occupancy
Net he is e.mpt Naefrom and Ne basis for Ne alleged exemption.Any violation of ^ P y Type
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of 3
a marc Nen rive hundred dollars(1500).
Laaawnerarrhe pmpary,army[.ploy[eawith o-11sotheir.m[compensation, Re .sired Inspections
will do the work,endtie s menne is mnot anended00
oroffered for age(Sec.90.Business
and Profmoom Code:The Conwcr's Lice.law does not apply to an owner o/
prop[nb
y who uilds or im movn thereon,and who don each work himself or through
N.own employees,provided that such improvements sure act intended or offered for
We.IL however.the building or improvement is said within one year ofmngladon,ds
builder will have the burden of proving Nat he did not build as improve f«pur-
poseof own`
co I,m owner of Ne Sar.70,1 ,B exclusively cmratimg wish licensed emaa.. m
nnrum the project(Sec."lona,asuman and my who W th;at i Dre Cmuaeon. end
ansa law dao not applyje ts owner of prapeny owed With;ser ant to I thereon,and
wM1m contracts for such projeca with a contnnodD licensed pursuant m Ne Conbalofa
License law. J -
I em[xempr under ga. .B&P C far Nia rwmn
owner Dna }`/1
WORKER'S COMPENSATION DECefoll—ON
1 M1and will man mica penalty of elemental
one of Oa follmfor duclanWarkee,Co
I have and will far by
a Sectionrtat,
ofC a LmorCore.fure fa Wohela Co of the
atim. r provided far by Satim 3700 of Use tabor Cad[.for the pertomuoee of the
ark for which this permit is issued
I have and will maintain W,profia Coma rd r w rk For which
h manuio-P by Section
37y, she labor Canis, she performance of shework for which Nis prrnit is issued.
My Warke{��° panmtion lnxurance certicr and Polity be
Certicr.�a"<-'�1 ni'r Policy No.: Z
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(This serious need nee be completed dine permit is foram[hundred dollar(SUXH
or las.)
1 employ
my that in the any
of s t work(a which this the W it i xural.res'Co I shill
not employ any perm#in any manner a n m become subject to the Work[#'Compcn-
Applilaws of California.Dna
Applicant
NOTICE TO APPLICANT.If,aha making this provisions
o of Latnptim, .y ahold
becomen campy the Wasters Compensation provisions of the rami Code.you muss
IonhwiN mmPly wish such provisions ser this punnit shell be deemed revoked.
CONSTRUCTION LENDING AGENCY
Q p Ih[.by uRrm thr them is a conamNon lending agency for perfmmoce of
it y
IN work for which this permit is Issued(Sec.3097.Civ.C.)
Larder's Name
a > hander's Addraa
lit Q 1 unify that 1 have rad this application and nut[that the above information is
0. col.I agree to comply with all city and county arduu«ea and swe laws relating to
z. rrabuilding coosmation.and hereby emlwriu.preaenwivn of this city to mem stpun dr
V C abuse-mentioned propeny far institution palpates.
is. f, (We)agree an save.indemnify and kap heaml«s the City of Cup[nino against
Q U liabilities,judgments,costs and expenses which may in my way meme against said City
in con.9ucau M Neg.dng of this permit.
i Ila SOURCE RECIATIOTANUSANU WII,LCOM VLY WITH ALL NUN-IY)INT
V z Sf1URCl?ItEGUTATIONK
Sigvm.of ApPlicanJComrata Data �_—� / �V V ��5• I
HAZARDOUS MATERIALS DISCLOSURE
Will Nc applicancnrfaro.building mcapsour Mardi,haxardaus romerial Re-roofs
v defined by the Courtin w Municipal can..Chapar 9.12,and the Health and Safely Type Of Roof
Cad[,ecdwTi53z(a)) PIGyP
Will the applicant orfuam Wilding mcupmt use oruipmem or devices which All roofs shall be inspected prior to any roofing material being
[mit heradous aircmteminmts as derived by Ne Bay Are Ab Qualhy Management installed. If a roof is Installed without first obtaining an inspection
Diaries) I E]Yet a ree to remove all new materials for inspection. Applicant
I have rsd do hm arandoroam' u `o
mund`s Chapser6.95of N[Celi. un erstands and will comply with all non point source regulations.
Safety Cade.Sectio.755 , 1533 and 25536.1 undersand Nat if Ne
uildingdoesarc dytrav[ mdw
almo . itr myreapna
omibilityaitY Na«uupam
of Ne torments -ch mu thae mFria. aarce ora cu
Signature of Applicant Date
Owner seg D
41
All roof coverings to be Class"B"or better
OFFICE