00020158 suOF
DING DIVISION CONTRACTOR INFORMATION: PERMIT No.
PERMIT Q ZQ ! g
BUILDING ADDRESS: ,
Q O TANrTv �y '/`'— �. Q��' SMotN� SANITARY NO. APPLICATION SUBMITTAL DATI
OWNER'SN li: 1v I l�(,e Y��/ 1 & ' �U�A
A VQGe- •1O ` —` SUA-0 LAAH- lA NIC CONTROL#
PHON_: 15% - I l g fi M.0111-".•1 JA L l l C4 L 4so3 7 ❑
ARCHITECTENGINEER 2-9 6-I tea 1 BULDING PEHMII'INFO
°00C
Q�W
16^ LICENSED CONTRACTOR'S DECLARATION
z o y e I hereby•(runs door[am licensed reader provisions of Chapter 9 f.rocung Job Description
Hv:w with Section] )of Division3ofde Bmi=sa ftfmiam Calc.and my license is
in full force and eRe
dx �(J2w SQrlIP/� I l k��
Odie bireme �;6 Lic.g 4aro1
>< Dam—LConsecmr
Cu O ARCHITECTS DECLARATION
I understand my plans dull W used as Public.cads
was
°° LicartN Professional
OWNER-BUM-DER DECLARATION
t 3 1 hereby of rso dust I am exempt from the Commormes License law for the
zS° following mown.(Section 7031.5.Business and Pmfmai«u Code:Any city«county
C which Maims a parmit m canstroct,aft«,itepro.a.demnusn,m.pair any rsuchorm S Ft. Floor Area Valuation
5_ prior to its issuance.else oximms the applicant for such pemit w Bleaeighedaamme.t q'
Net he is licensed yonumrto the provisions of Ne Cotaumis Liccnu Law(CWpmr 9
(commcncirg with Samoa 7000)of Division 3afdte Business and Pmfeasians Cede ce
NAPN NU r Occupancy T at he is exempt ahvefmNn
m and the basis nor e alleged exemption.Any sodiu of S p Y YPe
secure 7031.5 by any appticaot fine permit subiaLL du applicanno a civil Patient Of
non more Nen five hundred dollies($500).
❑I,a,owner.rano#aprnr.amyempt%'anawithw.gmssdaumleaomprnsatian. Required Inspections
will dome work,Cd Nenmcmm is nor imeMed W Law
does
(Sec.]Dan,Business
and Pmfesaom Code:rise vo thewr's License raw d«e nor apply himself owner M
hpro,artyis own wed builds or sided t s Merton,and who dose.tech work tid neor through
his own owentas,provided that such imp is sold u a.no intended W olf«ed tor
he
We.If,however,aur Wildingorin of pro int isatIswithinmmymafn,anne for the
polo mf Wldv will base the When or posing that lie did nor Wild a improve for per.
pose of talene
1,u r the prof aha See 704,am exclusively convecting with licensed censors to
consumer a n project ISec.]tan owner
of and Proleui Wild,
d,or The Conveaori nd
ne law d«s nen a{mlyje as owner.!pmprnY who Wilds or impo the Neaeon.and
whocontractsLaw.nor seen projects with aconannap)licen.d punwntwthe Conbedoh
License Lew.
1 an exam#under ga. .B k P C for this reaa.n
Owner Data vi
WORKER'S COMPENSATION DECVfRAT10N </
I hereby affirm undo pmalry of.f perjury one of the following deaat"s Fl co
.ravemid prooidln for
Cion 37 m of onsim to me Labor
Code,to, eprorkcr'e CWnpm O
satin,r provided fed so Section 3]00 or the LeWr Code,nor he pdenmarme of arse
work for which illi prmil is issued. J
❑1 have end will maintain W.hch Come aide,w Insurance,h requital by Secsed.
My We be labor Code,f«dm performance of ted work for which this Permit a issued.
My W.nkels Compensation Inxueuae cams and Policy number art:
Uma: Policy No:
CERTIFICATE OF IINN FROM WORKERS'
COMPENSATION INSURANCE
(TM1iesectinn need not Wcomplcmd aria prmut is for.ne nundredddlms(5100)
or less.)
1 certify Net in the performance of the work for which this pemut is issued,l shall
not employ any pcom in any mother to ea to Weeme,wbject to Ne WWketa'Cooper-
Wine laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Cenifica.of EaemFtion.Yau should
M1ecmhe subject on da W Wkce,Contlosvion provisions of she labor Code,you muan
forthwith comply with such provisions or this Much ahall W deemed revoked.
CONSTRUCTION LENDING AGENCY
0 I bey eRrm NU the.is a construction lending agency forthe perforrnssme of
Z the work for which this permit is issued(Sec.3097.Civ.C.)
cQ LeMers Name
y > Leashes Address
[� i unify Net I havd N
Int,'ranis eppl'rvion and save that ft abuse information is
Q. Qcorrect.I agree to comply with all city am county carbonate,and sante laws.lating m
rti Z building construction.and hereby authorize repesenative,of a his chymenmr upon the
V C�+ above-mentioned progeny for inspection purposes.
Rs rot (We)agree to save,indemnify and kap twmless the City of Cupnion against
[) liabilities,judgmume etre codexprose,which may in any,way acemeagainst said City
} y in conuqutae of the granting of this prount.
F Cl- APPLICANT UNDERSTANDS AND WI LI.COMPLY WITH ALI.NON-POINT
14 SOURCE REGULATIONS. '
SignaN..I ApplictooComma., Data
HAZARDOUS MATERIALS DISCLOSURE.
Will NeePplicam or furore Wilding acupont store.,handle haxudous mvecial Re-roofs
u defined by the Cupertino Municipal Cade.Chapter 9.12,and the Heem and safety Type of Roof
Code,Secti.n 25531(07 yp
❑Ytr ON.
Will the applicant or future building occupant sae muipmem or devices which All roofs shall be inspected prior to any roofing material being
emit hmulous air conuuniname as defined by the Bay Arca Air Quality Management installed. If a roof is installed without first obtaining an inspection
District?Q Yet ❑Na I agree to remove all new materials for inspection. Applicant
m i m m Chapter b.95.fthCall. understands and will comply with all non point source regulations.
have read the hode amaterial a d
ramie Health A,Safety Code.Sections 15505.25533 and 23534.1 underused Net if ted
building dhes not currently saw a unset,ther it is my msp«uibility in notify the occupant
of the"ointments which must W mea prior m issuance of a Certificate M Occupaay.
Signature of Applicant Dante
(honer or auNonred age. Data
All roof coverings to be Class`B"or better
OFFICE