00050006 CITY OF CUPERTINO ° PERMIT NO,
8UI LDINBDIVIS10N PERMIT CONTRACTOR INFORMATION: ,oD UDO�
BUILDING AOURESS'. �" n a
/ q 011oo €�s�w F2rMG Corp n ra%a,r1'9rk SANI'1'ARYNO. APPLICATION SUBMITTAL DAT]
OWN L I:S ME:
NIC COMROLp
d$ X2-5 —(0000
ARCHITEZ-fX-NOINELIt BIILDINGPERMI"r INFO
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'Mi LICENSED CONTRACTOR'S DECLARATION
OZ= I hereby aRhm that I sm licensed under prosisimes of Chapter 9(comms«ins 1� /' Job Description
F,viFw with s«don]000)af Division Sudden Busincuand Nofesumu Cade.and my It...is �eg�011"�10/� (JY'
EU inRllf«a.�-�L�.. 23633 abridge Over baba
« uanK Zq
3 t� Dau Contrecwr ram If re eIC 5
F a O Q ARCHITEC"'S DECLARATION
1 understand my plans shill be used as public records
an
o QO o
IJccnad ProfculorW
n¢I OWNER-exempt To DECLARATION
st hereby a(Srtn that 1 I S exempt from Ne Confeumm.Co e:Any c Law co the
5 O following morn.(Section]Ol Ld,Business and Profmionv Cede:Any city«coenty
m which requires a permit u construct,eller,improve,demolish,m repair any announce Sq. Ft. Floor Area ,� Valuation
prim to it,inn.n«,also lectures the applicant fnraueb puit
mm file.rignedsnme
dsm 35 0001
that he is licensed purswnt m she provisions of the Coubsc o/a Licente Law(CT.pn 9
(mmtne«ung wish Sectian]o0(yof Ml imcrn J Of the Business and Prefmiam Code)or AP Numbs Occupancy Type
Sassoec io is 31.5 b therefrom W the burs for the tS se aempit to Any lip proudly
of / 0 Jg P Y YP
Section703 them
LS by my applicant fora permit subjau dm applicant m e civil Pendry or (�
Ijm more Nen five hundred d011am y empl
LaaawMrartnepr'wens.nrmyemwareeawith wages..their sole enmpero.dan. Required Inspections
will do IM work utd the tae Cmu is unintended«offered fa apply
Buse,a
.oil st,whou Cade:The COnt«mrS License w law,does,rid work
hi s lf owner d
his own wlro builds on impravly Hereon,and who dors such work himself of through
his own employees,provided Nu such improvements are not intended or offered for
sale.If,however,thnbuilding«improvemcm la midwithinrineof impletion,
rico W rider will have Nc burden of proving Net he did not buildild a improve for P.,
ur-
pOK Of 6d0.),
co I,a ow«r of the progeny..m same s,just Profeddng with heaved contractors J.
cerne La d projat(ga.o. 9uei of and property
who bur Codec The COntatah IJ
cense law seas not apply o u,own.of propemy who builds or hmpravn Com m.W
whonse Laws for such projat with acanmecwt(s)licensed pursuant m the Contrecmte
0 Imo law.
+ ❑lam<aemp tinder Sa. for His nastn
Dan,
nu
WORKER'S COMPENSATION DECLARATION
1 herebyaffirm
bui under penalty of n,perjury oro of the following declaraWminers Cm
ossur
1 have and will feimdn eCeni37M OfC a Labor Code.for
for Worker's Compem
nit u provided ra by Section J]00 of the Labor Code,for the performance of the
«Jc for which Nis gamut is iaued.
Xt'1 love and will maintain Woke/s Canpens.uion Iuurutc<,as nquued by Section
of Ne labor Code.for N<pcdormenee of dte woh for which thud pcnnit in iswed.
My Wmile, C mpg -tionYlmura'� thrid and Policy nu yc
Cartier. J�a�+�" g-�A Policy No.:�7`"�
CERTIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This sewn.nml rid becompleKd if He permit is forooehuMred"Hera(SIM)
or In..)
I certify Than in the pedmme«e of the work for which Nis permit is iuund,l shdl
not employ any porion in any manner m be .1 1 Woheri Compere
notion Laws Of Califomia.pate
Applicant 1
NOTICETOAPPLTCA� Bu n Nis Cenif¢aII f Exemption.YOU should
become subject to the Ws Compcnation provisions 4 ills Labor Cade,You mast
fanhwi h comply with such provisions or this permit ansa he deemed cevoked.
CONSTRUCTION LENDING AGENCY '
I hereby affirm that dame is a construction lending agency for performance of
z The workfx,which dls permit is issued(Sen.3097,Civ.C.)
Lenders Nurse
yon } IaMeisAddle.Ga: Q I Unify and I haus read this applWbom and eWc that the above information is
0. connect.I agree to comply with dmnc
l city and county ordies and sure laws relating to
.7 z building COnSIONCO n.and hereby amhoria representatives of this city to enter upon the
V O shove-mentioned molteny for inspection purposes.
fad E., (we)agree to save•indemnify end kap hamdas the City of Cupertino against
O LJ lialnina,judgment,emu send expenses which may in any way accrue agaimt said City
} Lid in c.mwqueme of the granting of this Forum'.
h APPLICANTUNDERSTANDS AND WI I.L COM PLY WIT[I ALL NON-POINT
U •� SOURCIi REGULATIONS /s�W `-�1 —oo � •���
`DatSigraturtAAROUS 'i
MATERI IS DISCLOSURE
Will Noepplicant orfumre buildingox.panumrtor handle haxthdots lmteial Re-roofs
as defined by the Cupenino Municipal Code,Chapter 9.12•and the Health aM Safety
code.nation 2s532m)] Type of Roof
�Ves No
Will the.ppliea tar amrcb ildng«cnpanttK gtipm retard iceawhid All roofs shall be inspected prior to any roofing material being.
1 larardnus ab miturmmnt a defined by the Bay Arta Air chodiry Ment,smat installed. If a roof is installed without first obtaining an inspection
is'^gt] I a ree to remove all new materials for inspection. Applicant
❑tar g
I Mve red lhh g�g,�.i�.b.�ChW�6.95offtUi. Understands and will comply with all non point source regulations.
fmtia Huish&SduYC 4 the[ifrhe
bdldingdw nmcmrtn0y Mvc a Knmt,thth it is hat...
IwtifY the«apart
of the rtyuir h at uaua« CcmficaI—
o peay.
Signature of Applicant Date
Owner or eta zed agent —Dam '
All roof coverings to be Class"B"or better
OFFICE