00050083 CITY OF CUPERTINO ' - - PERMTTNO.
BUILDING DIVISION PERMIT CONTRA o' a ° N: (J���)•//qq//
BUILDINGADDRESS: ����/ `•'D
,4 �/K— ItARY NO. APPLICATION SUBMITTAL DAT
NNER'S NAME: // { NIC CONTROL#
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40ARCHI'I fiCT/`GINEER �/� �5 L /� e! / �`/ BUILDING PERMIT INFO ^'y'"
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sews
u
v: LICENSED CONTRACTOR'S DECLARATION
z O H 1 henby air=Nat 1 am licensed under previsions of Clupw 9(commenting Job Description
wiNSfinmer0o0) fD"sion3at TNeBmineas P/rqf Lill
is
^.a¢�¢ in full force end eRec Z V Y O " // 70 �/ a
see t� License Cogs o In_ Lic.N /r/C / �%^/-� / /H� V 'V ✓l
x 3 a Dan Conwcm /
ARCHITECTS DECLARATION
f y y undentup my pWn mlWl W used a public rearda
w C Licensed Proreeeionil
OWNER-BUILDER DECLARATION
t-Z Y 1 hereby am.that T or eaempn from Ne Continences Liecr ee Law for Ne
4 F G following..(Section 7031.5.Bwiwss,nal Pmfaiona Cial A,city Or my
3 which regrite.permit he ema l W.,impswO,demafiro,err repair pay smrewn Sq. Ft. Floor Area Valu�133n
prim to i0 uwam'e,,Ise requires the,applicant for such permit to file a signed come �j all
he is licensed Formal an the previsions of the Caneanol.Lianaz Law(Clusic' cp !.
(c.rucir, ithSeedut7")ofDNition3nfthaBumiaasandProreumnsCode)Or ane APN Number Occas Type
Nn Im es exempt therefrom and dre basis for the ellc,E cwmpame.Any mladoq o1, Occupancy YP
Seen..7031.5 by any Wheant for a pennivabjects she applicanno to.civil pewlty of Ra--cc
a more Nen f ire hundred dollen($50(1).
Lu owver of da prapeny,or my cmployaa with w,gem Ncinok compewd Inspections
will dothcwort,and din Theolurei ...1.Mnda Law
ripply. owner
and Rofeuob Code:The Convacmra Licewe Vis dote Iwl rl,co re it owner gh
hpropertyis..palm Wilde or improve,such i,alp wine don wch w«t himself a diwugM1
his own employeee presided Nu such imp,I.and i,an,ern i mr.f a pRered for
eile.If,howevwi the Wildingmen of roving
isoldwithin rineyeasofcompletion,m
r-Wilder will have Nc burden of proving Net he did Out Wild«improve for Fur- /J�
pose of sale.). T
I,u owl of property,,m exclusively converting with:)caned coma \v\ _
CO. ,mueshe projectct(Sao]060.Businessand ions ProfessCade:)The Cwaxlor.Li.
cense T<wdaamt,pplynoan hat.c tprapcnywW Wdpurriimprova Nereom u's
Le 0.Law..f«wch proiecm with•<onv,dor(s)licensed punuanno Ne Contra<mrs
License Law.
❑1 em exempt under Sec. .B&P C for Nis rtuun
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 herebyaffirmtown.ower penilny meperjury ossa of IW followmurre ieg derlandau:
I ,as and will fobySection
37W of Lbrtsem r self-Code.sun for fforma C,of the
workf r provided for mi Section 3]00 of din Labor Code,for the pcnfonwna of IW
work for wM1idM1 this permit is issued.
❑1 have and will ode,fon Wnrkeor Come oftheon Insurance,as his parr t i Section
I700of thea o Code,for inperf«m,neeofthework for which Nig Ftn^it is issued.
y Workers Compensation insurance curier.M Policy number art:
Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need net W completed trice,permit i9loronchuMrM dollen(3100)
ser 1x9.1
Toy my pini In Ne perfarmena of the ort fo which this anrintis iseved,I shill
Out employ pay pen n in any {jp, o W ecl to the Woeken'Compcn-
selion fo yrF�1°
Appli pal y �r
NOTICE IO AP ANT:IL-,lilcr making this Ccnificate of Exemption.you rlwuld
become subject to the Wont's Compensation previsions of the,Labor Code,you most
forthwith comply with such provisions a this pesmiuhall be decmeA¢voted.
CONSTRUCTION LENDING AGENCY
O p I henby afinn Nu there is a construction lending agency for dim performance of
z h the week for which Nig permit u inund(See 309],Civ.Q
Fen Lenders Name -
a } Lander's Address
ryI I certify Nal I have mud this application and gun limit rbc above information i9
derect.I agree to comply with all city end county ordinances and sum laws miming to
D z Wilding construction,and henby centuries mprcsenutives of Nis city to enter upon the
U O aWva-memioncd property for inspection purposes.
La. (We)agree to eve,indemnify and keep hanmleae the City of Cupertino against
O U liabilities,judgnunv.cosu and cape.which may,in pay way.raueagaiwt said City
} W
Ie....wm.of the granting of Nis permit.
[•. 2- APP NT UNIIER..WANDS AND WILL COMPLY WE I H ALL NON POINT'
V RCI:REGULA71 IONS.
gig ul AMEcanUConewele, Dui,
HAZARDOUS MATERIALS DISCLOSURE
Will the.,Ii.,or boort Willing ceetc nt retort«handle hiundaw meuriil Re-roofs
as,defined by the Cupertino MrNcip,l Code,Chapter 9.12,end the Health and Safety Type of Roof
Code,Seem¢25532(.)]. YP
❑Yes ❑No
Will the applicant a to,..Wilding occupant ase equipment or devices which All roofs shall be inspected prior to any roofing material being
chit berudous an contamiwnu u defined by the Bay Are AU Quality Mewm
gccnt installed. If a roof is Installed without first obtaining an inspection
DietricnP
❑Yes ❑No I agree to remove all new materials for inspection. Applicant
I have rend the heurdous mounds on,rbemenn under Ohl d 95 of the Cali- understands and will comply with all non point source regulations.
folie Heath A,Safny Code,Sections 25505,25533 end 25530.1 undersand that if the
Wildingdas n«cutn yhavea mit is my msprnury tonbiliyth cedant
ucmeyylh m tee Io usu,rce file an of Q
�..-f Signature of Applicant Date
e -rid agent D,u
All roof coverings to be Class"B"or better
OFFICE