00060086 CUPERTINO PERMIT NO.
DIVISION PERMIT CONTRACTOR INFORMATION: O� O p
BUILDINGAUURBSS: , ' D
A C SANITARY N(l. APPLICATION SDB IrITAL DATE
tlilw �� Notior�� Al/�
OWNER'S YAMG:
U •/A y1, `17 // ///7 U��[y{� N/C CONTROLp
El
ARCHITECI'IIiNGINEER � ,,5, is n//f BOLDING PERMIT INFO
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�F-N_ ( LICENSED CONTRACTOR'S DECLARATION
j z- 1 hereby emrm than 1 am licensed trust prpvisiona of Chapter 9(commercing Job Description ,
t•w w��,Tp Secoon]000)off) t 3mf a BusimsswdPMfeviom C[p,^ .0 mylittnseis
d j in life std effec is i/ /x �W s /��D/
O w¢U IJcr(((((('nse Cl Lic.M D�P /JD/D� /f//�
3,`i Dat used
L escrel'r�- 7
u O g ARCHITECTS DEC Olg
Comn
I understand my plane shill be used u public
%> O u erred Professional
W
OWNER-BUILDER DECLARATION
C?¢ 1 hereby shiner that I am exempt from the Contractors License Lew for the
w€o 'following reason,(Section 7031.5•Business and PmRuions Code:Any city m county
m �'which requires a permit to mn
mvu ,alar,improve, m
deolish,m mpvr any,uucwe
a3- prim to its iaau.nm,also requires the applicwt for such permit Mmme a signed atateem Sq. Ft. Floor Area VI IOIIO
that he is licensed puuuant to the previsions of the Conracmrs License law(Chapter 9
(commendngwithSemon7000)vf°ryislon3artheBnsi^casandProfeaammCeds)m P umber -Occupancy Type
+ Jut he is exempt therefrom and the burs for Ne aflegW calk or Any violation of ������
1 Section 1031.5 by any epplicmt(m a parterre subjects Jou epplicwt m a civil penalty of
d pt mom than fve hundred dollars($500).
I,as owner err theimpot..ormyemp1'.with wagon u duir sol,cooperation. Required Inspections
wflldo the work,and the mucture Ice.interMed mafieml for ale(Sec.7044.Pursue.
and Profeuiou Code:The Contrxtm,Lt..law dose ml apply to an owner v/
Property who build,or impmres thermn.and wine dm such welt himself or thMugh
his own employees,provided shu such impmvemenu art not intended in offend for
sale.If,however.Ne building in improvement is sold within one yeti of cmmde ion.me
owner-builder will hall the burden of revving that he did net build or,improve for put-
pose of sale.).
C]1.use owner of Ort(See
un exclusively confessions with Beamed contractors i.
mmwct the project..1, can w.of and Professionswbur Cade:)The es thacwra Lit
sense law coca mtehpim be
an owm of property who sed p or improves Co..std (/
who seU.sfar such mojaa with acenvactar(x)licensed pursuanum the Cantndms v
License Law. O
❑1 em exempt under Sec. .B&P C for this won
Owner Dao
WORKER'S COMPENSATION DECLARATION
1 hereby affirm see sir pem4y of perjury,ore of me following deelaramins:
4I hove aM will mainwv a Cmifinu of Cel sent to sel6inwrt for Warkcrs Compen-
tion,as provided for by Section 3700 of the Labor Cade,for the perfomurce of the
for which Nis permit is issued.
Out,
and will maintain Wodrers Compensation Insurance,u required by S,nion
Out, clabor Code•fm JrcpKomna of Jrcwmkforwhichthispmilisissued.
My Workefja Jfynygs�tt curia and Policy
M We Policy No:
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This rection need but bacmnpleeed if the permit is forme hundred dollop($100)
or Icae.l
1 certify that mum perfomerce mf Ne weak for which this pemdt is issued,(,hall
mi employ any person in any menenr m u to become subjecno the Work,n'Compere
astimn laws of Cdifomia-Due
Applicant
NONCE TO APPLICANT:If,after making this Ce"ifies a of Exemption•yon should
becnmc subject m the WMcss Compti abort provision,or the Lata,Cade,you..at
runhwith comply with such provisions or this permit an.](IS,deemed revoked.
CONSTRUCUON LENDING AGENCY
O l hereby affirm that them is a mnahmtion lending agency Seethe perfumuvice of
z the work for which this permit is Issued(Sec.3097,Civ.C.)
lenders Name
a > lander,Address
LeaE 1 unify that 1 have read this application and mutt Nat the above information is
A4 z comet.I agree to comply with sell city and county ordinances and state laws relating m
.7 z building construction.and hcmbywthoniu represenutwe.,(chis city be enteeupon the
V 0above-memionedpmpeny fee inspection purposes.
4. E„ (We)agme M aave,indemnify and keep hanmleas ane City of Cupertino against
0 U liabilitimjudgrrcnu.1.W expemea which may in any way accnuagsimt aid City
;,4 W to sentemsrc,of the ganting of this permit.
[� CW AI'ILICAM NUI' til'AND'SANU W11.1.COMPLY WIT II ALL NON80INI'
f..) z SOURC i l .0 1'I SNS.
9S APPIicmU nuactSpr�a7e—
FU MATERIAIS DISCLOSURE
Will theapPlicantmfuwrcbuidingrccupanruortorhaedlehaaaNmamateriil Re-roofs
as defend by the Cupertino Municipal Cade,Chapter 9.12,end the Health mdSNny l
Ced,.Section 255320)+ Type of Roof
r]Yes
Will the applicantm uwre Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
coot hnandous air conumieanu as didimd by the Bay Area AU Quality Management installed. If a roof is installed without first obtaining an inspection
1ni7 I a ree to remove all new materials for inspection. Applicant
❑Yes No
VIP Ih.ve mW the lis m,materiel,mgnir,menr,neden L„apteeb.95 afth,G.li un erstands and will comply with all non point source regulations.
Co..Health&Safety Code.Sections 25505,25533 and 255 M.I undenuM Jot if the -he
buildingdacsn um atepmt.NatitismYrtsponeibilirynenmifyJreucupmt S
of the ire u test be Mesptiw 10 unuarce of a Cenificeaof�eC9p
O nu suthm eda l \ /16nLY/,., SI tut of Ap Date
All roof coverings to be Class"B"or better
OFFICE