00100062 CITY OF CUPF,RTINO
aun.DING DIVISION PERMIT CONTRACTOR INFORMATION:
MaLIIING ADDRESS, J' 1 l 1 I I PERMIT NO.
r� /de/,(.. OQt j.OV.IQt62
OWNER NAME: p/' �L API'LICAI'ION SUB DATE
f'!� S �J vT 10/09/2000
HONG, - _ 'ANIFARY NO. CONTROL No.
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lIUILI ANG PERMIT INFO
OC ARCMITEC'OENGINraiR: - (IQ$, �G/ n��'Z - LDG CLECT PLUMB NIECII
Z y LICENSED CONI RAC'IORS DECLAItA9'ION O DeRCFIption
O z H 1 heahy.(firm mm 1 am roamed under priori me,of Chapter 9(e mn¢reing
yCu( with Sell 91X10) fD'v" n3 of the It...iness:md prUl...w., ,�nJ my hcnue
<x — is inrtmfacts Be � DEMO — 1tD00 SG. FT.
.y.�C y�,rsrn
�z� I.ian.eC r,a1�C1✓� ua.n�
3 a. Umc /�arrl� Conlm Injgr1k�1 - -
V I AHCHI'rLCr'S DECLARrk nor
.g tmden.l,md my plan shall he u,ed m pantie crook
ce
o x Licunw1'mresainn
d al _
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OWNER-BUILDER m the Car,
1- I naso affimu that 11. excmpl from the Cnnma,Cos :Any a Law for the
�'E following moron.(Section 91131.5, t,all zs not vet demolish.
Cole Any do lar county
-L C
which 4 re I I c t ct II Improve,1, I:M1 au 5_t acre
c 3 that p p I. 4 fpr a I I n I 6 I'e tecol
,o he Ic scepursuantn d C . oncContractors i1 (Chaptery Sy. Ft. Floor Area Valuation
ten I rhes teem Section rumen ,I he basis
3 tt e alleged e x U d ionrAny n ction $5000
n,Sbarec toe is exanpt Ihercfmm ant the nazi,hu me estheexemption Any violation
of at,,m,7031 eIll.,, by any applicant for apemlip aunjreps the applicant mocivil penally
ulm,t moa man Ewe hmdret tnlwrsfs.5rgn. APN Number fn Occupancy Type
01.as uwnetof the rroperly.or my calploy—with w::ges ns their.volc coml,emcflon, :7.7934171F.8, L710
will do the work,and the stmemre is not intended or offered lin sale(Sec.91144.
Babas land Pous ions Code:The Contractors License Law does not apply to a„ Required Inspections
omoor of proper,W'h t builds lar impmve,plateau,and woo does Bach work hiln.nll
r through his own enpinyccs provided that such in,pro,emems an not intended or NO ASSIGNED INSPECTIONS
ortered for sale.II;lin r.Ih.nodding a mph aur i,sold wohin o c you or
Ven,
Ioro c,c lo,the owneri're.).will nave the burden of raving that he did not bulla lar
mprove rnr @vpunc ul're.).
❑I,ns owner of the prupeny,am exclusively cnnpmcdng with licensed contmnors u)
Ln,mel in,pnjen(Sce.9044,businessand Nutrition,Coic:) Ihc C... orl,r,
icemw Low does not apply man net of progeny into Imild,lar inquiries Iherenn,
and who oonlon,to such pmjccn w'an a 1 uloatnrhsl licensed pu"aq u,the
Contractor's License Law.
01 urn exempt under Sec. .11&P C for his reason
Owner Dam
WORKER'S COMFENSA'1'ION DECLARATION
I hereby union Under pcnnRy of orjmy one of lin following decmrminn` /�1
0 I have and well mcido,d l Clo,Secti of consent w self-insure,aboure for Worker's �V�-
Cnmpmenceo, or,he work
Earl fist lav Section 391x1 0l the Lunar CWe, for the L
pedi,muance of the work for which prix pemuit is izvrcd.
01 hove and will maintain Worker's Compnxapion Insurance,as required by Section
311X1 of the Labor Coln,tor he it aanee of dm wink for which his permit is
issued.My Worker's Companemion Insurance carrier and Policy nwnber are.
Conic,: policy No.: '
CP.RTIPICV'ION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Phis section need not he completed if the Hermit is for one hundred dollars
IS 100)m leen.)
I amity ram in he perr,nnnno,to Il,c w k for which or,pe,n",is imred,I
,bull nm corp >K. any h o become subject m he N'nrkcri
yCnniciamT � rxn
I Applicant
NOIICU APPLICANT:IL C ape n C visions f of L'xolhor o dyou uhau t
bceomeh comply with
it such
Compo ad on provisions n b,deemed Codc,you nn:,a
Q 0
forthwith comply with heli pmvi<ion.or,thin Ircrmit shall be deemed revoked.
Ftoo CONSTRUCTION LENDING AGb:NCY
a > I looby rdfin Ihru there I,a um.Inednn Ic"One,agony for the performance
W of he work for which his permit is issued(Sea YN)9.Civ.C.)
S Q Lender's N:mw
= z Lender's Address
U 0 I eerily that I hrne real(his appliedion and ,are Ilial the ahnvc inlbnnetion is
F.r correct.I agree in comply with all city and cowry ordinances and state lawn totaling
Q [�
to mildin6 rI'lloon,mailli by anallorim repreoomorives of this 'city t terlpm
the h m I I property fInspection P rpr-
H y t W)ng t malonallify and keep harmless the City of Ca,scitins,against .
4 Irub I I e: judgment: t-and cxpcnws which aily an ally way talcme toolanst sand ^
U z City to consequence of the gm i g f th' P m I
^' AI'PLICA 1NDERSTANDS ANU 1 V. YWITH ALI.NON-POINT Issued by: Date
SOURCE ALAT
cig�a stn :� meta - Date Re-roofs '.
uA5RDous,IAr b%I DISCI.OSUR13
Will due apprcartt m future building occepam soic or hanmc ha,Lnlars rmnerml Type of Roof
ns defined by be Cupertino Municipal CMe,chapter 9.11 anA the Heahlu and Safety
Code.Section 25532(x)?
O Yes 0Nto All roofs shall be inspected prior to any rooting material being installed.
Will the appucnmo,future mildhtgnauhum useegim, car ordesicc.whirl, If a roof is installed without first obtaining an inspection, I agree to remove
no nwadous air comannnams as defined by me Be,Area Air Quality Nlanagemem
istrier;r all new materials for inspection. Applicant understands and will comply with
Oyes ON. , all non-point source regulations.
1 time read the hvardous nrnertoh requirements under Chappa 6.95 of the
Gdifomia Health&Safety Code,Sections 25505.25533 and 25534.1 undetxl ind hat
it the M1uilding tax not curmn9hiet
hug a"my responvibility trillion,the
1 cupmu f the require cot, prim m ismawc of a Cenificute of°ce° Signature of Applicant Date
o„ to,mhorovdagent Date All roof coverings to be Class "B"or better
OFFICE