00020101 CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: _L0 (0
BUILDING ADDRESS: s s SANITARYNO. APPLICATION SUBMITTAL DATE
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OWNERS A)E: _ / /^,n nv,,I c1�{I ���� � \//� <(� NIC CONTROLN
'ONC: �O B� \ O l I, ( '//y/ l/W\ �Q9J` ❑
ARCHITECMNGINEER `� lBOLDING PERMITINFO
EDQuw\-i:5
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LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Nat 1 sm licensed under provisions of Chapter 9(co ming Job Description
wiNSection?a0r virion3of the Business and Professions Code,eod mYli<cnse is �
F J Ill Trutt sod.ffeeeRat. (ocl �0 G�
as ueenu nandn fuu<.«
o.vDFi Dote Contracbf
p4 ARCHDECrS DECLARATION /A
I underssand my plate shall be used u public rands O YH
5
6 p z PD
Limensd Rofeuional
OWNER-BUILDER DECLARATION
7 1 hereby&Rom Nat I sm exempt from Ne Comramer License law fm Ne
I F e following reason(Section 7031.5.Business and Prormaions Code:Any city or county
i3 m which squires•precut m comment.alcor,improve,dcmnlish,an mpa'v oY smr°""e S [ Flo r Area Valuation
primto its isstruce,al.requites Neat'licam f...ch pexnutto fileuignd.."= 0 O
Net he is licemed yu....I to Ne provisions of the Contracmes License law(Chapter 9
(<atmnenmn,gwiths«tien7000)arorviximt3arNeBaaineaanaProreWmacde)m APN umber ccupancyType
th,t he is emmw marrrom w ars the brte the alleged"emptier.Any,violation m ` O Q 3 Z 1
Section 7031.5 by any applteant fa a pemut subjects N .
flue to a civil priority of J I
Ela morn Nan five hundred dollars(5500).
1,W owner of the,property.or MY employer,with wag"a their sole compression. Required Inspectio
willdothe work,snd thesnun e,x is SM man do 1 m official fm We(S«.7044.Business
and 9ofessiom Cade:The Curer L License law does hat apply to co owner o/ /
properly who builds or improves themnn,and who does such work himsslf or through
his own however,
ma providd man such mens is Sold
art no iyeaNW m oli"rd fm
WuIf,however,the Wilding rimwovemrntisaddwithin t your improvetiou,de rY/
wnemboildcr will have the Gorden of proving Net he did not build or improve fm pur-
pose of W a).
I,as owner of Ne property,am r«luaivdy connecting with licensed conteareas ro
contriver the project(Sec.WW,Bminca nM Professions Code:)The Contractor's U.
cers,Lew does not apply in an owner of propcny who builds or improves theeon,and
as connects for such pr'eca with, ntn Ile Or
License Law.
l am eeemw un
Owner Dam
WORKER'S COMPIENSAUQN D N
1 M1ertby alarm un penrit
Ihave pamukll torby. mfi onsenO
smirk,r providedforby
work for which this arml
1 have and will rminain Worker's Comwnsetion Inxuren «
3700rf Lir b s
MY Wurk<rs Com and 1 rum
Cartier: a o111111 D
CE Fl O S'
COMPENSATION INSURANCE
(This section tied no IS,completed tf Ne permit is folmehudrrd dollars(3100)
m lea.)
I certify that in the perfomwwe of the work fm which Nis pcmut is iave4l shall
not employ any p<non in sky menrcr am as to bmane,mons'm thr Warton'Comwm
saran Laws of California.Dae
Appheant
NOTICE TO APPLICANT:If,after making Nis Certificate of Escmptiok,you should '
Werra subject to the Workers Compensation provisions of me Labor Code,you must
forthwith comply with such provisions Or this permit shall W demand mokd.
CONSTRUCTION LENDING AGENCY
O C I hereby obtain Out theorise cmksrmmum lendingegens,leads, d...f
Z the work for which this pmnit is isssed(See.3097.CO.C.)
Leaders Name
F lander's Address
I unify Nat 1 have rod this sMlicalion and state that Me.bove information is
17e carat.I agne to comply win,all city and miserly ordinance,and Bute laws mbung m
Z building construction,and hereby authorise rew"enutivcs of this city to enter upon the
V C) aboveamc boned propacity for inspection patrician,
Lt F, (We)ague to save.Without and keep harreleas tie City of Cuprnn,a against
O U lix,IMx,,jSgmn ,.,mhS ed apemss which may in any way aarveagainst aid City
�w W M monecqurnce of Ne Mnun,of this permit.
F+ L APPLICAN'l'UNDERS'I'ANDS AN1)W,1.COMPhY WI'I'I I ALI,NON-Ml N'I'
N SOURCE REGULATIONS.
V r Signature of Applicanti0mnamor rate
HAZARDOUS MATE RIALS DISC6
Will afmum Wilding Occupant storecalono aNusmuat
defined by the Cupertino Municiwl CodcChapter 9.12,SM the Hedth um Safety
Cale.Satuice 2532( ? �Type of;R
Po�of
❑Yes
,No
Will the applunum or future building occupmt use equipment or devices which All roofs shall be inspected prior to any roofing material being
SM havrdmis air contaminants as defircd by the Bay Aro Ah Qa
(healthy MasUctnt installed. If a roof is Installed without first obtaining an inspection
renin° I a ree to remove all new materials for inspection. Applicant
❑Yes
Lha rtdNeharudou matedaleagaiamenteader�maptaA.95aftheG.Ii�
understands and will comply with all non point source regulations.
folia g does n Scurry Cade,genions 23505,is my axp 23534.I notify
M Nat if Ne
Wilding fines nor currently have a roam.Na it is my msponsibiliry to naify the occupier
of the requirement,which must W met pria to usua«e of a Certificate of Oce lumerY
Signature of Applicant Date
Owncr trat t Date
Z lY QQ All roof coverings to be Class`B"or better
OFFICE