00040154 CITY OF CUPERTINOPERMITNO.
ell,I)ING DIVISION PERMIT CONTRACTOR INFORMATION. (-1/y�/r) ,� S J
BUILDING ADDRESS: 'fir �-y ) V V j-
/ffj Orc,�SNI/�� p/ti GLS , EAl< //G�� SANITARYNO. APPLICATION SUBMETAL DATI
OWNER'S NAME: n' /7)� /•Nn/ '.s .Q's[L N/C CONTROL#
ONC: IV ,✓I sl�L/n� lcYK IJiTN q51 7-
517— ❑
ARCNITECf?:NGINF:IiR LlDk q 3/ —�, L s/ (/ BULDING PERh1R INFO
C,CW z N1,4 ff!! T b 7 j 17
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LICENSED CONTItACnder p DECLARATION
a o_o I hereby amrtwn Red
n t l.ren ander mviepm of Dhavmr 9(rammercmg .. - Job Description
H¢mr J wiNform]00o)of Divixion3of Ne Businessand Professions Code.and my li«nu is
K z d< in fuill force sed ellen. �y
fig
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Lieeno,Class • Lie.N
v3.O S Dem ARCHITECTS DECLARATION // "�YtI N ' /0 E
v�Q L I anxssand my plans shall W used az public records
w i 0 Ouschocd Profes.loe.)
c w OWNER-BUILDER DECLARATION
I hemby arcsm that 1 am exempt from she ContrutoYs License Law for the
f'x G following reason.(Section 9031.3.Business and Pmkuiom Code:Any city ae county
which rtgolm.Permit til mustrucl.alcor,improve.xmoliah,.1 roper any evacmre
3� prior to its issuance.also requires the applicant for such pmN to rile a signed mummers .Sq. Ft. Floor Area Valuation
N ..
ethe is licensed purswto Nthe,ns e provisions of Common's License law(Chapter 9 Z V / 0I.L]
(commencing wish Section 70W)ofDivision 3 of the Business and Professions Centel or APN Number Oe u ane T
Wt M is exempt therefrom rise e huffs for Nalleged!e allegedexemption.< mptian.Any violation of 2/ Z _ O _ D Z P Y YPe
Section 7031.5 by any applicant for a Fermis subjects the applicant to a civil penalty of irlJ
pt more Nen five hundred dollar(55001.
I,as owner pr dupeopeny.mmyemway«ewiNw.gussNcvwle=aroemdlov. Required Inspections
ori II de Ne work,and the structure is notintended ne offered for We(See.7045.Biomass
and Pofeuiom Code:The Contractor's License Lew does was apply to an owrcr a
property who builds or impmvu Hereon,and who dose Such work himself or dueugh
his own employees,providnd this each improvements are,na inundnd or ofland for
We.If,however.Use building or improve.,is sold within one yearofcomplemar,she
owner.Wilder will have the Wrden a proving shot h=did oro Wild or improve fins par-
as
w-
as ow.).
t ❑I.u owner of Ux Set 70,am exclusively contracting wish licensed concessions,ro
\ came I-a the prong(Sec.o an ownHarer
of I and Professions Cnde)The Copuacwta V.
cense Law cts f no,apply to us owner of pmputy who Wdas or improves threnn,and
who comms far such pmt«Its wish a conaecmdq licensed pursuant m she Contractor's
I «u L w.
❑`I nm eaemp under Sec. .B&P C far Nis rwon
Owner Dem �/
WORKER'S COMPENSATION DEGT,ARATION /
I hereby affirm under penalty re ofCon one of the following Wrd,m'tiom:
I have and will maintain eCenifcaa o(Consenuo self-insure for Wohei s Compen-
sation,as provided for by Section 3700 of the Lmor Code,for the performance M the
xo for which Nis prmR is issued.
I have and will numu n Wnrkeh Compensation Intim.,as required by Section "
�f ] of Nelabar pCgeade.lf+a Urc pertpcmmarce o/Ne wart far which Nispumit is inwcd.
and Policy
C.WorkcYs)Cpmb+t'! In/N��exam"PolicY
C. or
M
CERTIFlC O OF COMPENSATION
FROM WORKERS'
COMP.,late ON INSURANCE
' Obis vctim rcndnahcomPksed if Nepmnit i.(oronehundreddalen($100)
a kss.l
I employ
any Oat.the perrorm an ns sh.suet for whichthis permit is iesuea l shall
I rommploy any person in y nrcru so bg nv+sabje tm)thc worken'Compem
nasion laws of r 1 � '
APFlicanl /after
NOIme, .O t to the L after mating n mfcam de,UN,C n.you should
hecome euomp to it Worh pr Compensniis provisions of Ne Lobar Code,. must
forthwith comply with such provlilons a this premix shall h d«md avoknd. '
CONSTRUCTION LENDING AGENCY
Q 0 Ihereby of rem Nn Nem is comtrucuon lending agency for performance perfounce of
z 2 Ne work for which Nis Permit is issued(Sec.309],Civ.C.)
F,e Iandres Name
a > lmdeeo Address
Lz7 E 1«nify that 1 have read No application and state Net Ne above information is
F. z comet.I agree to comely with all city and coamr ordinandnces asmm laws relating to
Z Wilding construction.and hereby amhon«representatives of this city to enter upon the
V abovememionad popsy for inspection Imp nes.
(We)agree to save,indemnify and kap harmless Ne City of Cupertino against
0 U Emiliues,jud,nomm antsand upnam which may in any way acme agent,said City
>y W in corse nee of sheBmn,ing of this permit.
NU'Ntil'ANDS ANI . COMPLY WITH ALLNON-K)l)IFN�I'
V Z SO, 'S'"PIONS. v —�l L{ 8
roof A/ppli,mLrC.m, I Dam �S O�
HAZARDOUS MATERIAIS DISCLOSURE
Will the applicant or fmurc Wilding«cvpantzmreor hvdle haudous matted Re-roofs
as defmd by the Cupertino Municipal Code.Chapter 9.12,and Iha Health and Safety Type of Roof
Coda.Section 25532(0] yP
0Ycs
Will the applicant o (wort Winding eccupanl on equipment or devices which All roofs shall be inspected prior to any roofing material being
hot haaa
rsrdoua air conmmnas defnAreaed by the Bay A •An Quality Management installed. If a roof is installed without first obtaining an inspection
yrs I/(Nn 1 I a vee to remove all new materials for inspection. Applicant
`o
havetidtheh„ado emimnd•rc9 i menaand rC Fa h.95nfN Cath. understands and will comply with all non point source regulations.
Toccoa Neave cerry Cox.have
m us x33 and nobi, erwo'm it the .
bluWdgrtrlg docs rely ustloenet xis my rcvof.cih anaifY «cupant
, which mons he met n«r ssuanee of a Cen c re of Occupancy.
0 a _N Signature of Applicant Date
Owner or euthorisnd egem Dare
All roof coverings to be Class"B”or better
OFFICE
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