00020055 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: OOOZO O<S—Q5—
BUILDING ADDRESS:
WAT/q/�] H��-rq�f��gGN//J(tet oLLY/J,//rl� SANII'ARYNO APPLICATION SUBMITTALDATI
MUl(q L9t NIC CONTROL#
IOAF)2192_ Clr-o5c, da/iey, 9s9s-
r ARCHITF.CDENMNEER /— -933 —g572 BULDING PLRMI'IINFO
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LICENSED NSED CONTRACTOR'S DECLARATION
z o„'- 1 hereby•RRm that 1 am n.d liccuMer provisions of Gluier 9(wmmencing Job Description
QCfd withSection 7raitt Division3of the BusimssaM Profasiom Code.eM my littn.is
in fullforce WeYsu s !/✓afV/ /a✓afVr ' 1(���C Tj�!�
3 z 6 License [CTq D
a H Da¢ Convenor
C u O S As"I ECTS DECLARATION
I understand my plans still be used u public roads
0
Licensed!Pmleseioml
c utS^ OWNER,BUII.DER DECLARATION
t:z< 1 Worby al.rhn I me exempt from the Canuacum,Liam Law for the
—S D fallowing reason,(Section 7031.5,Business and Professiom Cade:Any city or county
w t m which requires a Permit to cons re",else,improve,demolish,or repair any avunwe
a5— prim to it,issuance,als.re uires the"ficant forauch Permit to file asignedruumrnt Sq. Ft. Floor Area /j Vns7luatt It
diet he is licensed pursuant to the provisions of the Cusm.crs License law(Chant-9 7(J(/•aV
(commencing with Section 7M)of Division 3ofthe Business aMProfessfonsCode)m enc APN Number Occupancy
that he is..unit therefrom and the heir fm the alleged esson m n.My violadon of P Y Type
Section 7031.5 by any applicant for a Fina t subjects the applicant o a civil penalty of 7 Q
or Nar more an l,,hundred doll (5500).
1.as owner of the Pmistily.Or my employ.ea with wages as their solecompeneation, Required Inspections
will do the work,and the shommrt is not inuMedoroffercd for We(Sec.7004.Business
and Pmfahionu Cade:i.Canuanm's,and w few des ret apply to if owom of
pnianct Pry who builds or improves thereon,and who dace such work apply
to r or through
his own employees,Provided dw such improvcmenu art not intended or offered for
�le.If,cildm withe buil dingmimpmscment is sold within Ireywofmprove for the
owmnWilderwill love the burden of leaving then he did not W ild a improve for pm- ��
poo of retee L
1,as owner of the properl am exclusively contracting with IkY�connaetmr to
or.Lan the Project pply.. n Business and Profession,winei Cher:)The Co theme.
Li- '
be, law dao ren apply je an owner of prnpmy wed Wilds or improves comom end /
who contracts for such projects with econvacmrtq lanced pursuant m the Canrtutoro
Li,1" Law. O
1 am cumq under Sec. .B It P C for this reason
Owner Dam
WORKER'S COMPENSATION 1311 7PION
1 hereby affirm uMer penalty of perjury one of the following declantimu:
I have eche will maintain aCenificare of Comets to elf-insuu for Workefr Compen-
oon, provided fm by Section 3700 of Our Labor Cade,fm the per ortmnce of the
4wor orwhichtnir Permit is issued.
h
have aM will maintain Wonkcr's Compen.tion Insurance,u minted by Section
3700of the Deno,Code,for the performance of the work for which this Permit is issued.
cam
2 mpc BMW
comm and Policy n
Cartier: F E Policy FROM
12L{E S�S
CERTIFICATEOF COMPENSATION
FltAN WORKERS'
COMPENSATION INSURANCE
(This action nets nM he ComPlemd if the pemtit it krone hundred dollars($1130)
or Icer.)
(certify that in dr any i moor of so turn
run which this held is issued. "I
our employ any person in any mmmr m u m become nubjmno he Watters'Compen-
utlon aewa of California.Dau
Applicmt
NOTICE ub APPLICANT:IL atom meting this Certificatesof the
Labor Cod you should
hecomc subject y it Wortrh Comp.1 this provisions of the IaWr Cade,you men
forthwith comply with such previsions or this permit shall fx deemed mokM.
CONSTRUCTION LENDING AGENCY
O O Ibercbyaffirm Nu them is a Construction lending agency for the perfomusnce of
sZ tithe work for which this permit is issued(Sec.3097.Civ.C.)
Lenders Name
[� 7 Leodcrr Acidness
I certify that i have reed Ilia application aM swe Out the above information is
Ao Il2 correct.I agree to comply with ell city and county oNinances she rue laws Heisting to
;D Z building crosuuction,aM hereby autheri.apmarreaves of this city to tour upon the
V Q aWvc-mentioned property for inspection puryoses.
Ci (~ (We).'.to.eve,iMemndy am kap harmless on City of Cu,cmnso agalnlit
O (J liabillties,judgment,Cos.and npenm whlchme,in any way accrue,iumu said City
to con.queme of the granting of this permit.
fw APPLICANT UNDERSTANDSAND WILL COMPLY WITII ALL NONdNIN'r
SOURCHRF ULATIONg. G&
Sig.of Corrector Dam
AZARDOUS MATERIALS DISCLOSURE
Will IicanlmfuwuWildingrccupmlstomorhaMlehawdousmalend Re-roofs
err defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Type of Roof
Code,Section Z532(.)? / YP
Oyermss'
Will the applicant or future building acupmH use equipment or devices which All roofs shall be inspected prior to any roofing material being
eunit#.mous an conumimen.as deftnM by the Bay Am Air Quality Mringenrcm installed. If a roof is Installed without first obtaining an inspection
District? R.( I a vee to remove all new materials for inspection. Applicant
Yes
Ih.verandthch.,..dam nowetial .coder Chap.,695 of the Cali-
'
ali- understands and will comp- with all non point source regulations.
rcquircmrn
•tomo Health A,Safes,Code,Sal A)5.25533 and 2590.1 undensrsnd than The Jj
Wilding docs not currently hav num,inn it is my im,onsibiliy to..if,the pass,
/ (�
of the"cin n W Hct pniw w iuuarce of a Cori& a of cups y.
2-1
// Signature of Applicant Date
ITvmrm eutW Bc Dam
All roof coverings to be Class"B"or better
OFFICE