00120151 CITY OF CUPERTINO
]BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: e00 Z 015
BUILDING ADDRESS: PERMIT NO.
OWNHR'S NAh :: APPLICATION SUB DATE
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PHONE - SANITARY NO CONTROL NO.
0uOO ARCHIIECUENGINEER: BUILDING PERMI LINFO
BLOC ELECT PLUMB MECH
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Q�I•i 1=1 I_I GI G'I
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S y E LiCENn I it a 'rRAC1 OR DECLARATION Job Description
pO 2 t hereby vtirnt Nat nm of1he B ander nand axion.sitm%Code, nd illy license
F v+_w isin 7000) Jtl the BusincsnanJ l'ndessinns andlaylicense
6,j J Ir In IUB InfCC an}�.fBefl q �]
C a,C :ieenscfl.tss-``may .RC I DHCLA • `4
Dnlc(�(�'/�Y 3— Gommelin
t-LL C I-n ARCHITECT'S DECLARATION
g I undcraunJ my Plano ahold be need'es public rccnnA
ap LiccnscJ Ro&ssional
o y
OWNER BUILDER DECLARATION. e Coundr
=' 1 hereby.hien that um cednp,%want,hc Commcl Co I.iAny a latw for the
followF>.0 which
xire ma,requires
a(Section]oust liu.imc and vet do fnli Bodeetry city n,rnture
5=0 wM1itM1 rtquiree a Irani,m cnmwah alma improve,Aemolinh,or rtpnir any structure
mo nn,nPrior ukm ayuim,the uppfmnm farsuch Permian filao,,,laknlow.,
a-3e- that he is limnxd powart la he powikam,of tic Commnnr.Lima,law(Chepmro
(cmnencing with Section 7000)of Division 3 of the liueinen,and l'mf,,oum,Cale) Sq. Ft. Floor Area Valuation
m
n,that he i.cwmp,Ihumtmm and Inc banis Ior the alleged exemption.Any violmian
of Section 7031.5 by any drift icunt lir a wrmit submla the applicant to a civil penalty
it moreNan roc hall doom.($510). APN Number Occupancy Type
❑I,atnwncaofd,pmp_try.army ctnployfes will,wage an lhcir.wle conttren,mlon. '
will do he work,and the stutume is no,intended or oReled,Lr sale(Sec.7(A1, ,
Business and Prom slous Gxle:The Contractors Limove Law does not apply ro an Required Inspections
orr m pro, rly who hands or Inipmvn Ihcrean,and who do,,each wort.Itiln.df
through his own empicyem,provided that such ilnpraveticats am no,intended nr �'
offered for sale If however,the building or improvement is sold%thin one year of IV A LE D
mnplmimt.,he owner-httilJcr win little the bunlon of proving than he did not build or
improve Gr pumovc of sale.)
Ell,usown.,o1tn,,prnwny,nut...to,ely orad lin,wit,h,,ao,d foulmldr,lu MAY 2 1 2001 .
construct,he project IS,,.70.U,Business and 1'nalle,on,,Code,Due Contractor's
License La W does not apply m an owner of proreny who build%or improves thereon.
nal who ntmmts dor such ptnjdvs volt a contr:nitons)licensed Pur u.ml ,o the
1 , axunde ISw BUILDING
❑I am exempt under Sec. .It re P G for this reawn
Ownca Date
WORKER'S COMPENSATION DECLARATION
I hemby all i under Penally nl Ir�my one of me fnllnwing A¢lurwinns.
❑ 1 have and will maintain a Cenificata of Consent ,o self-insure for Worker's
Cmnprnsad... clodth
as provided Ibt by Se 'mn 9701) n1' the Labor Ce, far e
performance of the nod,for which this rental is issued.
❑1 have and .It tuuintuin Wnrker'e Cnmpensa,ion Inmrt c.a,miNirN by Section
371X,of,he Inde Coda lotThe ierlonnmme of the work dbr which no Nout Is
sued.lily N'ad.vr s Compensation Insurance carrier and Policy number arc:
Came,:_- Policy No.:
CER'IIIICAI'ION OI'EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE "
(This section need not be comple al tithe Penni,is for one hmmdml dollars
1511X1)or less.1
I cemly that in the reifirmence of the work ror which this permit is issued.1
shall not employ tiny person in any manner.o to mJ�cop chli 6, the Workers'
CmnpenaetJ�//��JJ��yy^^ �I,�diyfytf1y Uu,c T V
APPlican,/r"4s`7/�" �J
NOI ICE"r0 APPLICAN/'n�iL'ad`ier,mmakmg mi.ceniyf to of Eaetn,nom.you should
,"anse subjcm"''he Wet kaa'e Contpen.ttion pmvtmw s of the Labor C,.le,you non.I
O fnnhwi,h comply with such provision,(it r This Permit shall be deemed revoked.
FCONS"I'RUCI'ION LENDING AG17NCY
> I hereby allinn that them'rs a umsloactinn lending agency for the perhanan m
W of Ne work for which this permit is issued Iscc.30)7.Co,C.)
0. Q Lender's Sit se .
Z I.coder s Address
V 1 ecnlfy Ihn,I have dad This application and wa¢,hat the a nve infomu,ion is
Lam. F torec,.I ugmv m.comply with all city and county anlinuncca and one bows retina,
Q V :n Wilding dmswc,ion,and hereby authorize rercsconamts of Nm is cityenter ti
ty [yd ,he nWw.menroned proreny for impKlon pupates.
61
(We)again m cave,indemnity and ke,hu...I...the Co,of coria.'....u mnx,
F tT liabilities,judgments,trusts and eapeni which may in any way aneme aguinw said \ 111
U City in cnmequcnm of the granting of this pvnni,.
'-' APPLICANT UNDERS"I'ANDS AND WILI,COMPLY WI'm ALLNON-14)INI' Issued by: Date
SOURCE.REGULATIONS.
Slgmnurcol'AppremmVCmtlmma, Doc Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumm building occupant sin¢or handle M1arardwus ma trial Type of Roof
n defined by the Cupertino Municipal Cndc,Chapter o.12.and the licalm and Sale,
Code.Salton 4553210?
E)ye, 0 N All roofs shall be inspected prior to any roofing material being installed.
Will Nc alt, Tam as mare baild'ugoe,,an,n.m egmpmdn or del ice'wltivll If a roof is installed without first obtaining an inspection, I agree to remove
emit bvualuus air contmninams as dein,by the Bay Area Air Quality Mon igdnctn
.� Di„rid? all new materials for inspection. Applicant understands and will comply with
Dye's 0 No all non-point source regulations.
1 have nal the hil,l,Cod, nctioo,a reg5.2553 ae under Chapter 6.Brom of the
if llfornil building
o,re Safcur Cndc,have
a hs mn5 d ,553?:rod 2.553 1.„mm t,to nosh lh e
is occupant
of the rwm currently whit umvL be met prior toy rmance of
Ceniotily the
reorient of Inc rc.ryimn¢nt which mum ho:and prior In issuance of a Canilicam of
/L _ Z9L,0C) - 1 azure ('Applicant Date
Owtcr ase., Dom All roof coverings to be Class "B” or better
OFFICE