00030058 —'1
c`tCY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
SANI'I'ARYNO. APPLICATION SUBMITTAL DATE
o •s �3
NIC CONTROLN
' � � �/iywo�'a L/9 9ns�IS%s'�722 ❑ ,.
ARCHITECIENGINEER� Q/J��yU/Z BULDI NO PERMIT I N FO
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y¢i
F- LICENSED CONTRACTOR'S DECLATI
ARON
c y= I hereby aRw Nu 1 thn licensed trader Provisions of Chapter 9(commerciog Job Description
�m=ei with Section 9000) D)A n.3 of the Business and f)a,tom Cade.sad my leause /�////y%//,/n /'�/D JL/L� p �i�//�//�///��/� 7
�za in roll forceaad eRecLLst /, ✓VN/V� �/�/ � �< //(•e�/� / �9`7/L O��N✓
Liu as ams, I.ic.N
3 LL vOFi Date Convector
cm O� ARCH=S DECLARATION IV
t-•'• I un ierauad my plans shell be thud n public tccads
E 5p
lica,ed Profcuioal
c o, OWNER-BUB.DER DECLARATION
t Z I hereby dE.Unit 1 an exempt from are Contractors Licenu Lew for the
E s C following rerun.(Section 703 1.3.eumsen and Rofa+iam Code:MY city a county
c, m which aquim a pewit to comwa,slur,improve,demolish,m repair any swcnue Sq. Ft. Floor Area Valuation
prior m its issuance,dao requires the applicant for such Format to file a signed statement 15-he
5 Q q.
that M1e is lian,ed Wrsuant b the Provision,of the Contralorm Licaa law(Chsgn9 !l Cl
torte us'sa p, gectlon,andth basis for m theBoll aim send Pa.My nded.m APN Number / Occupancy Type
Wt he;s essvgtt therefrom and to boas fee Ne af1egN<xemptiw.MY violation of �
sm,mom
dera.6 v,any applicant fee a Pemd1 subjecLL the eppli<at to a civil Fealty of (�sJ
I mote Nen Evehundredty.W yeml
h.
wi I.asowmuof the pro,twi.wmr employees orofergaaa their auto compensation. Required Inspections
will do tom work,ands: WCmnwcawi Lt.. wow do for We Illy
1.44. melof
mad ny who
Cade:The Co dearer Licenu law does caw apply to lf owns of
popery oro builds or vides!do ssuch i and w W does such work dee i if veered gh
for his own employees,Provided!Nat poen menros wild w thin caw amended n reared far
ole.If.however.do,buildingmimpmvemenn i,told whinone ild ofcompletion,the
a -Wilder will hare Ute bursa of leaving than M did caw Wild Or improve for pv-
Coni
I,u owner of the pes.704.B eaoners sand confession,with licenud eortttsnors 1'
,a. a the project(See.o sh Owe,
of mad ,who Wild,
s Code:)The Com enesm.V
cenu law does not apply je m owner of poppy who sed F nr ion in
Nme9n,and
wocanvects fm such wojecu with a conbactot(c)I;Ca,ed pursuant to she Contrsctar,
License Law. a
I un cxempl under Sec. .B&P C for this span Q
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penaity of perjury roe of the following decWuimu:
1 hove end will maintain a Cenificam of Consent o ulGinsute for WorkersComPen-
t as Prodded for by Salton 3900 of Ne torr Code,for the perfowarce of the
Forofm which Nis permit is issued,
1 have and will maintain Wornmer Compensation insurance,as required by Section
3900ofBe UW,Code,fm the perfor adenofthe wort for which this Permit u issued.
My Work/y G9ptgyp�gR y_y s/ue". and Policy SAW!
Cnida. (V/JAYTI Pand lacy Y _
CERTIFICATE OF E E,vu OON FROM WORKERS'
COMPENSATION INSURANCE
(This satin need cad bccomPleudifthe Pemat is forum hundred dollen($)110)
Or loss.?
I oy my pens n Ne my mormar in Ne week for which his the Wi;sissued,i shall
rot employ any person in any manrcr u as to became<ubjeet to the Wurken'Compen-
setion taws of California.Data
APplicmt
NOTICE TO APPLICANT:If.after malting this Cenificam of Exemption,you mould
W,a me subject to the Workers Compancedon pmviumm,or Ne tab,Cade.you must
foMwith comply with such Provisions or this pewit shell be deemed revoked.
I CONSIRUCfION LENDING AGENCY
III O 0 I hereby afEw NU thea issued a conetmcllon leading agency for e perfowm anof
.Zw
i iNe work fm which this peit is is (See.3099.Civ.C.)
I<ride,a Name
ye 7Unch,<Address
W I canify the,1 have mad this application and awe that the move illfomtamor is
a correct.I agme to comply with all city and county Ordinances sad sure laws raising to
Z Wilding communion,tad hereby authatize aptcunmlivn of this city to enur upon the
rJ O aEm e-immumed poperty fm inspection Pamaaas.
Lm r. (We)agree no save,indemnify and lamp hswless the City of Cupertino against
O U liebil;tire,jadgumi cora and eapema which may in any way aceme against aid City
W in consequence of Ne Brandng of this pewit.
(• IL APPLICAN IUN1ERSPANDS AN 11.1.COMPLY WI'I'1 I ALL.NON-POINT -
U ' SOURCE RECI' >DONS. ^ �� �•p ��' `�
w� Signm m of Appli t Orr G . v V
Oe MATE RIALS DISCLOSURE
Win Nc applicon 'taloa Wilding occupant store or handle hazWous ttutedaf Re-roofs
rep defined by tad Cupcn;nm Muhill code,Chapter 9.12,W the Hat and Safety T e of Roof
Cade,Section 255321 yP
❑Yes
Will the applicant at future Wilding occupant use equipment m devices which All roofs shall be inspected prior to any roofing material being
mit hnudou,air ronumiantz a^de by the Bay Arca Av Quality Mvugement installed. if a roof is installed without first obtaining an inspection
.ming I agree to remove all new materials for inspection. Applicant
❑Ya
I have read the haardnw meudafs mania thunder Chapin 695of Na Cali understands and will co ply with all non point source regulations.
fano Health Ar safety Cade,Sections;2553,2 .3 and 25534.1 understand that it the
Wilding does not currently hc amam.N rsmy rtspomibiliry cry Na pmt /Q
of the mauiremem which �to remi.e of a Ce ni m f ecu
Q Signature p Ic• t Date is
Owner m asuthodzedagent V
All roof coverings to be Class"B"or better
OFFICE