01010116 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
\ 'G ADDRESS; • PERMIT NO.
0¢SAy"ti VA Y � � ja m is R„kvk 6f O ( 0 / b//
!)N,
iR'S NAME: n nO 2, APPLICATION SUIT DATE
, ,?e.+� R X/11/ PD . rJ4X 3,67
... i: _ SANITARY NO. CONTROL NO.
Wi6 — 01 $ 5` 54eOt j4,C4 �IszJ�
D00 ARCIIHITCt'4iNGINIiIiR: 11 `�f) fsl11LUINO I`IiRM1'I'INFO
oVj C RSD %o-7 6010 . BLDG ELECT PLUMB MIiCH
hay CI CI J I_I
y LICENSED CONB'RACTOWS DECLARATION
oz=0 1 hereby anim,Bam 1 ret rcen.ed under ptovi,m,is of chapter 9 aa...menemg Job Description
2 wt-,u wish Semon 700(folDivisin113 India,Bacnelutd Pocaaitns Coda wants,l iucnss
—$ is in full forte andj'If'vc `'
R C re6 Licerne CWes (..�_ Lie.b 1e.leiI
3 u u Una_L�.Zgo_�µl Conuneun"I�w..�[(�5 nQ..�� A
ri. ARCHITECr DIiCLARAfR)A••� � ,,
I"LL O g I understand my plans shall be used m public meurd..� ;
C yW.6 5 VV ffff
wd i p�p Liccn.seJ Pml'csannal
c
OWNER-BUILDER DECLARAION
H
W 1 hereby affirm thusatIT
m1. exempt fnnn the Contrumm'..License Law far.he
C=a tallow ire n a renc.inn 01onstr ❑,.:less and improve,
demob Code:Any city n ure
E x o which it,i-c a peal..t to construct,pliers improve,demolish,or mama any saccate
l.3= pro, to it,ivwaana,nhn tcquim>.hc applicant in such permit.arile asigned samnum
mal lenli<e,t.ed ponaaau11 de..mei.iao.annecoam,e,or-.Lleen.a ,Chapteto Sq. Ft. Floor Area Valuation
kannnencing with Section 7XNp of Division 3 al the liminess and Professions Code) .
or that he is exempt therefmau and the basis for the alleged exemption.Any violation
of Suniun 7031.5 by toy npplieant lin a pcooit.abbe..,he ell:ieunun a civil"I.Ity
at t cre than live haani dollurs(s500). APN Number Occupancy Type
❑I,us nwaer of me property.or m).employees with wages as their ole eo.ttpeuwtirm.
will do me work anal the anicare I,non intended or unlcrcd tot sale(tire.9194,
Business and Ihofosions Code:The C m.mmnrb License Law doe,rat apply to as Required Inspe'd
matter of property WM10 build,or improves thereon,and who does such work himxlf
or tnruugh his own mnrltyecx.Provided Ihat such imprvvcmenl,v are not'atended or
offered far sale.If,hoarse,the building or impnrenm.n is sold within ane yea,of
cnmplel the rier-builder willhave th burden f proving,(it.hedid not Wild or
apo p To. f l l
01,as owner oftM1 properry.ran exclusively contrarling,withlicensed contractorsto
Lconstruct to project s 9144 Business d Professions Case) Th C t enor's
vc Law dre,n Irly. f prolactry who but Ids or anprovcslova,
and who contracts for.such pmlecu with a con.mo.on.I licensed punter. It the /
commcmar s License law'.
❑I Bin cxmapt made,Sce. .II k P C lin,his rclxoo
Owner Dane
WORKER'S COMPENSAId11N DECLARATION
I hereby athno under penalty of perjury one of the following dmlaration.c
❑ I nave end will ,nuinmin a Certificate 111'C11nsen, In sIl'-imsare I'm Wniker's
Compensation, as provided fur by Section 399 of the .Labor Cook, for the
,sedormance of the work for which this pemtit is issued.
❑1 have and will maintain Worker's Compensation Insurance.as requited by Section
37X1 of the Labor Code,for the perfann arc of the work for which.his permit is -
sued.My Workers Coniaenxallon Insurance currier and policy number mc:
CurnerACe policy No.Iya.CNIS-1d—o0
CHID IFICATION OF E%F.MYI'ION FROM WORKERS'
COSIVENSAI'ION INSURANCE
This wrlion need not he atmpineJ if the perm.t is far Inc hundred dollars
fBIaB orI'll.I
I certify that in the perfnmance of the work far which this permit is issued.I
,hull nor naploy my person in any....nater...as m become uhjen m he Workers
Catttprnvadon Laws of Carfomla Date
Applicant
NOHCE'TO APPLICANT.IL Lifer ,nmking this Caraftate of Exeomien.You should
Mete,..ohicc.Lit the Worker's Conmfun
en,alprevisionsof mu I,ahor Cud c,yoo,it I
O forthwith comply with such provisions or this fiction..hull be deemed rooked.
- Z
F ^ CONS'ere is a ONL1cND1 NG AGEgenc
I hereby which
his permit is construction lending agency for perfnrmmnce
W of me work for which this Penni.is i>sucd(Sec.31199.Co,C.) _
0. Q Lundcr's Name
IsndcLs AAdress
U 0 1 cenity.hal I base read this earl icaion and ane that the aMwe informal on is
R. P correct.1 agree to stntply with all city;aid l.,1 1y onlhtances and sate laws relating
0 U to Wildmgconometinn.and hereby anduaire representatives of thiscity me,ner upon
r W the aboveaemioned ,,,,by 1m inxpccum.purposes. .
Fut 0. IW,)a,,ro,sit ndetnany'and keep hxnalew the City of Ctpen,nongmn.,
V) liabilities,j al,menu,costs and expenses which m. any way accrue against aid
U Z City inconsequence of the granting of oris;' t t.
APPLICANT UNDER, ANDS AND O 1. WITH ALL NON-POINT issued by: Date
r SOUR B iD T I '$. t y'
Sign, ,I'Appli 1107a'117,,rmr :)ate Re-roofs
HAZARDOUS MAnxlA1S DISCLOSURE
Will the applicant or foam Wilding occupantstore or handle Wmmkms..amdal Type of Roof
as defined by the Cupertino Municipal Cod,Charter 912,and the[health and Safety
Coda Scotian 255126,1?
Dyes 0N All roofs shall be inspected prior to any rooting material being installed.
Will he appfeanlornm,a hudding,eenrun,ata e,Iaipnocal ordcvior,which If a roof is installed without first obtaining an inspection, 1 agree to remove
Inti,nueuNotis air corm ain:a 1,u,def i icd by.he Buy Arca Air small,Management
• Di.mm all new materials for inspection. Applicant understands and will comply with
Dye El No all non-point source regulations.
1 hme mad the hamNous materials requirements tinder Chapter 6.95 of the
California Health.@ Safety Collet Senors 25505.25533 and 25514.1 understand that
if the holding does 11111 cuacntly have a.roan.,,ha.o Is In,mop„wibility o--lily.tic
eculant of the requirements which must Ie ml. f a prior to issuance oCenirnae of
Occupancy. Signature of Applicant Date
Owl.eroruu.horLrlagent Date All roof coverings to be Class "B" or better
OFFICE