00120006 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
1
OWNIiR'S NAM:: — — - APPLICATION SUB DATE
PHONE: _ SANITARY NO. CONTROL NO.
ac
qq00 AHCIIITECI'/IiNGWEBR: BUILDING PERMIT INFO wBLDG EI.EC`r PLUMB MECH
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Qui CI IJ 1=1 1=1
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LICENSED colvrena'oR'su[cLARn1]ON Job Description
O<FN O I hereby a1Enn shat l nm Ii.enaJ ander pmvi.wnn..of CluWnct 9(rnmmencing
p,y .ma ai m Scctioneland'iDivi.inn luf Ne lfusinesx:cul Pmfessinns Ctde.and myliccme
yy in all font andcllicl.
is
Class. Lie.d n
F g d U note emnmett„ TENF ROWER ROLE
w_-m h ABCIETECT'S DECLARATION
O< 1 understand my plan,shall he used as public records
ear., LiccrtvJ Prnl'e"amill
e' OWNER BUILDER DECLARATION
d=m 1 hereby alTrm,hat I am carona from the Comru<mr'..License Law for the
Ga Hollowing muslin.(Section]031.5.Business and Professions C:xle:Any eity..reounty
�E p wldeh rundl\u:t peer..to eon"mcl.ane,.in,in„v e.demolish,lar ar,on,any Ir,mmre
I��y❑3p
Your to its issuance.also mtluims tileappllcam nesaehpermalo Ill...ignetl,lorcrcm
tha he is livenscd puauan. ,,he pollutions ofthc Contrecmri License low'(Cnapter 9 Sy. Ft. Floor Area Valuation
Irommencing with Sectinn 7000).1'Divisum 3 of the Business and Pmfesaiens Cade)
or that he is exempt themi'mm and the basis for the alleged exemption.Any violation
of Section 9431.5 lay any npphemn for a permit sahj,,I,the npplluunl ,in civil penalty
of am mi..mon Bve hundred dchaa Color)). APN Number Occupancy Type
01,as uwnet of the pmpery,lar my employees who wase,as heir sale compensation,
will Ju the work,and the smectum is non intended or offered for sale(Sec.10eb, 362105023.
Business Ilmd Proofs. ,.Cela II,,Ceatmcli(t License Low chic,ant apple m alt equired Inspections
at m
towner
of his aro won nulla,lar ovided t thereon,and won Joos such words intended
lf
or
lar through his own employees.provided than such impm t is sol Elie not ire year or
.nh,m for slue.ILhiweveh me hu ire altmdcaro fewrOhau he did one year of 304 — ROUGH ELECTRICRL
nmIF r,,,lo,mnpo,eontdmetwilu,av nehardenirprovingmatneaiamm�aimm' 501. — FINAL_ ELECTRICAL ENERGY
clnpro eh„nmpca erx:da.),
01,at cane,af,hc pmpm,amrvansively em,tea<.m,win,licensed enatiall 505 — FINAL ELECTRICAL
construct the project(See.9144,Business and Professions Ctdu)The Ca nration's
Lleense Law claws nit apply to an owner..!proPvny who bund,or improves the,ron. _
Inn who) mbne,fns such pollees whh a umtmchmsl licensed put'u.mt ,,Inc
Contractor s License Law.
01 am eaentpl under Sec. .B N P C for this reason
Owner Date
WORKER'S COMI'13NSA'I]ON DITLARA'I'ION
1 hereby u0rm undo penalty of perjury one orf the following dalararm,: /
O I have call will mninmin n CmlalCme of Conserv m self-insure lour Worker's
Co,I p'r I J f by Section s issued.f tire l h C for the
pert.. ,asire its.. whichlh'.Action 3
0 1 have and 'will maintain Worker's CaraNnoinion Insurance. required by Station O
110(1 ut dic Lust,C.It,for M1 I the k to,, touch h:Ilet I is
sued.My Worker.Cu,Iatnatio,In..l e oaruer and Polic,injure,
Corrie,: Policy No.:
CERTIFICATION Of:17XEMPf1ON FROM WORKERS'
C'UMPENSA ION INSURANCE
(Un,.action need not he am,pleted if he permit is for nuc hundred Jallan
(SIM).1 las.)
I serol,mut In the pc.I nnn.e of the work Inr whud,Ibis peon..,Is issued,I
shall not emplay any pemon In any n er so am:ts ,become subject the Worker'
Compensation Laws if California.DateIn
Applicant
Not]CE TO APPLICANT:If,oriel ul.lking this Cmifcate or Excnll yen should
Z Ise cnm cvnhjvut lel he Wer Kees C,lepsustain.,pn, 'ms of she l,aN„Code,ynunual
Q Q ha hwnh cmnply with such paovlsinns or Ibis,enlul shall be declared Invoked.
G CONSTRUCTION LENDING AGENCY
FC' ' 1 hereby a1Enn than mere i,a censtracenn lending agency lot the perfetmonec .
lar mo wild ln,which lhie per ms is awed(See 3091.civ.c.)
G p Lmuhr's Nature
= z Lcndet's Adders
U O I cemly that I nave read Ihis a,plicminn and state that the above ink riati a is
Da is unmet.I agmc m cnlalpfy wish all city and...mlly..Winnnoct ead.tum Lows relaimg
U In huildiny.onarvnlnn,and hereby uulhmim represcntaivesifihis city lot enter upas
the al.nx-memioned property for impeclion pampas.
f y (We).,me to ave.indcmnily and keep harmle.ahe City of Cupenino against
VZ liabilities,judglnems,units and expanses wh'all may in any way¢eche against said
.7. City in emce,ucu cul the grumar,of his permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.'DINT Issued by: Date C
SOURCE REGULATIONS.
SiymlteelApphvem/Cemramr Due Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding icalpal.Commtit hamhehacramismmenol Type of Roof .
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Senior 255320)'.'
Elves 0No, All roofs shall be inspected prior to any roofing material being installed.
Will tire hpplieant o,future building(ecapantuse equipment our des ices which If a roof is installed without first obtaining an inspection, 1 agree to remove
emit ha.nrdin s air cemmainanit w defined by the nay Area Air Quality Mociagemem
DimrielI all new materials for inspection. Applicant understands and will comply with
ore. DNo - all non-point source regulations.
1 have mail the hwardoun materials rellor anents under Chapter 695 of the
California Health&Safety Cade.Sections 25505,25533 and 25534.1 understand that
if the building doe,not currently have a tenant,that it is my amptmsibility to,nmify the
icoraof the myuitenernts which urn,be mel prior to issuance of n CMim ate of im e.apancy' Signature of Applicant Date
Dollar,is,amforimdaban Dam All roof coverings to be Class "B”or better
OFFICE