00030038 CITY OF
ENO 03003 'g
PERMTN°.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: pp
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BUILDING ADDRESS: 11 p (� A 1
2 S' y I„VIN I,ir SwI,N h a SANITARY NO. APPLICATION SUBMrRAL DAT
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ARCH TIiCf1ENGI ?Ell 1 '•Lo - L� I C� 9 q S O.S BULDINC PERMIT INFO
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j LICENSED CONTRACTOR'S DECLARATION
Oo-G Ih<uby./firm N.t1amlicm uM pmvismor Cn.pw9(c«s ming Job Description
F=LS"m wish Section]000)otDiviaion3ofN Busimssr Profaimu Code.andmylittnuis J
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S ca m Ueu �ITECTS'DEror TION \ S 1
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u u)S Oat I am exempt
front
DECLARATION
C 1 hereby.Kort onn I am exempe from Ne GssionGlola Licmu Lew for the
rc
O following .mm
n.'(Sian 703 1,5.Business.Buains. Pmfemvm Code:Any city or county
which roquim a pemou m comment,after,improve,demolish,or repair my ammmse
i3_
prior so its America,, inquirer the applicant f«ruchpmrdt m file.sincdal
gnement Sy. FI.Floor Area V81U�a1llonO�
Nat he is licensed pusumtm lhepmvisionr of the Coeleamola Licenu taw(CTuga 9 Som V
(commencing wish Smtion 7000)ot Division 3 ofthe Bottom and Professional Cotic)m pN Number Occupancy Type
that he is exempt therefrom ntd the basis for me alleged exemption.Any violation w /� / / P Y YP
Section 7031.5 by any applicant for a permit mbjects the nppiment...ivil penally of U
rot mum then five bandrnd dollars(5500).
C11.armmernrthepropmy,amyemployraawithwagaarmeirmieenmpema;on. Required Inspections
will dhdm woh,end do he Cl re is M s LimmoroRernd for We(Sec.]Dat,.Budanu
and Profuhob Code:The ver dintm's License Ido more trot apply to lf owns w
progeny who builds or impmvn thercon,.nd who d«a each woh hied or or Nrcugh
his own employees,pnvidnd Nat such improvemnts eart not intended xu offered this
We.If.however.dim building oren of
it sold withinoneildori improve
the
or-Wilder will M.c the busmen w posing Net he cid na build or impose fm pm-
❑L as ower of the Sm.70 sonexclusivelyand contracting with 11<ehami conmcmn - -
crriveLasNetsma(Sec.](u4,wnerof ropertywho hoi Co des The esnmcton,nd
came Law darn«applyje is owner or mmar who builds or improves thereon,and
who
mse l-acu for such pmRcb with a comnnnNd licensed pursuant m she Contmcmh
Beano law.
❑Iron exempt under5ec. Dole fa Nis rcaron .
M
' r Dae
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one ofthe follmaing llml.mtihm:
ll�ve and will mdhtdp•Cerdfiwm of Conant m calf-insure for Workers Compen-
msion,as provided for by Section 3700 of the labor Cade,for the perfortmtrc of the
..,it for which this permit it isauud.
have.nd will nu1nW n Worker's Compensation lurnome e,as required by Section
'My We the fabar Cade,m.Ne performance of the w«k fm which Nis petrels is issued.
My WorkeNa C9rgp<_nsa4hnlnsurame enols and Policy nu bar are:
Garner: aY yJT- f,�s{, Policy No,:
It it:
CERTIFICATE OF EXEMPTION FRO ORKER
COMPENSATION INSURANCE
(This radon nod not becompined ifshe permit is mronehundrcd dollars 15100)
or It..)
1 cenify that in the prdurmanec of the work fur which this pmol is issued,l shill
rot employ any .on in my manmr,so as m become .bjec1 to the Workers'Compen.
intim laws of Califiesom Date
Applicant + _
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you.Mold 1
becoran subject to the Workelr Compensation provisions of the tabor Code,you most
Forthwith comply with such provisions or this permit shall be domed revoked. .J MAR. 0 8 2000 II
CONSTRUCTION LENDING AGENCY
C Q I hereby aRtrmNar Vere is a construction lending agency for the perfin ce of IJ
Z Ne work for which Nis permit is issued(Sec.3097,Civ.C.)
FLenders Name "sr
a Lender;AM., c—
W I certify the 1 have tend this application and state Nat the above information is '
0. Q correct.I ague in comply with dl city and county ordinances and scale laws miming to
;D Z building coasaucuon,will hereby action.re reunwiver ofthiscity to enter upon the
U O above-mentioned popery,for inspection purposes.
W p Owes)agree to rave,indemnify and kap harmless the City of Cupertino against
Q U Iiabilidee,judgmems,cru and ransoms shichnuy in any w.y¢emes,mon said City
�. W inchnuquemeof Ne mongof Niapemiir.
[. N APPIACAN'I'ON STANDS AND WII.I.COMPI.Y WI'III AI.I.NON.FOINr
U Z SOURCE REG
Sigrcamrc ApplicenVCnnnut« Date A
HAZARDOUS MATERIALS DISCLOSURE:
illy the
ertino Muni building acupantaorcof handlehuvdore lSaity Re-roofs
as andio the Cupertino Municipal Code.Chapter 9.12..std the NdN end Safety Type of Roof
Code, 0Yes 25532(a)l YP
Va
Will the applicant or future building occupant um equipment or devices which All roofs shall be inspected prior to an yy roofing material being
sh.aallous au contaminants as definol by Ne Bay Arc.Ab Qudiry Management installed. If a roof is installed without first obtaining an inspection
40 °i°ac° I agree to remove all new materials for inspection. Applicant
s ❑Yes No g
I Yes
ha>udamrm.�idam<9aimmentsande.Gh.ptnfi.95ofNeedi. understands and will comply with all non point source regulations.
mmin health& ety Code,Sections 25505,25533 and 25534.1 understand that if the
buildingeos c ntly have a unrot,that is is my mrponsibility mortify the occupant
wNe reyu' ren be ren pei«to iaruerce�Cen' etc MOccupmcy.
Signature of Applicant Date
pew Bent Dau
All roof coverings to be Class"B"or better
_ OFFICE
t