00050040 (2) CITY OF CUPERTINO PERMIT No.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: `� ^^ �t
RUILDINGADDRPSS: /n//�j/ �/u•,"/ O O�+ V V � 0
/�' &V 0u/J/SD��'// U}tJa/�r�y SANITARY NO=ON DATE
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PHONE: J IVB/ yr,'• ' NIC CONTROLg
AR C511TIiCT/ENOINEER
FOLDING FERMI"f INFO
d
F°Z LICENSED CONIRACIOR'S DECLARATION
GZ=C 1 hereby aRnn the 1 un liccved under provisions Of Ch ner 9 fcommeaing
p=tty with SdinaccO..7OX).dDlisinn 3ofNe Beat.,uM Pmf room Cab,and my license is Job Description
s in ranfmnadenal
3b►3or Sot 4.Linodd �le� ��p�a�vrne�� 5G yr,k
°0.ac F Deu N
M a Contra-CL
t N° ARCHIIRLTS DECLARATION
w ¢p 1 Understood my plans eFWI W usm u public suds
°• �1 Leaved Pmfenlonal
OWNER-BLE-DER DECLARATION
t Z< 1 hereby aRmr the l am,amps from be Conlralofl Liana Law for Ne
'x
a followa
following reasoner,lgection 7031.5,Enamor and Professions Cade:Any city or county
�a 3 z which requires a permit in comvucl,alter,improve,demolish,or repaG any a mo,
prion"ie isruanca,ala reclores the applicant for such Ito file au S Ft. Floor Area ram,
Nat he is licensee rs,,a signed q• �va ti9i/)
pSnuanno Me Comb,... License law(Clugn9
Icanmrencing with Secdon 7000)of DivlaionJ of Ore Businen and Profeuionr Cndetor
Nat he is eaempl IWefrom and drc basis for be a lleged,ampffdn.Any vhdM.a of AP Number Occupancy Type
Section 7031.5 by any epp6ant f«a pemduubjecl,he Wdicaat to a civil pastry of ��, t/2
«more than five hundend dollars(55110).
will
Lo ownerof Ne pestractiche,amyo intended ed 0,offered ofergesuide(San.compema0on, Required Inspections
and do Newark.and the se Connisn«imas.Un.too, WWlyhoOCO.owner,Nd Proparty who
Code:Tru oyer therm,
Lionise law dw rwl apply Io lf ownsgh _
his--why builds or improve Chinch i and who does stanch work himself aoo,for
his own o ever,the provided thin inch e,o is smau a,e no,yunded a oRered for
We.If,howeserithe Wildingorimproveovin is sold within aleyeaof improve
for d„
owe.fs older will have Uu When of proving Nat Ile did hot Wild«improve for pury
you o(ule.). ,
❑1.u away of the Propend•nn evclu,ivdy oremdng wllh liaved marams to
eneveacl the project(Sr,.7Uea,Rusmav and Prefeaions Cade:)The Co onodra u.
cease law dons nm apply to an owner of propcny who Wilda ar improv,Iherton,and
who Lim.Lafor such prolan with a contra,or(q IicenaM wnlnemr't
punnt to the CA
License Law.
❑lam aemptunder ga. ,B,P C for this reason
0. Dam
WORKER'S COMPENSATION DECLARATION
1 horeby affirm cadet penalty of pc jury one of Ne following dccluati0v:
1 Mve end will Ireinaln acenlfcareofcauenl In self.inase forworace.Compen-
tim,a provided for by Section 3700 of the La We Code,for do perfomuoee of the
for which Nia permit i,iatnd.
QI have and will meinmin Wnrkefs Compenxetion lannance.as required by Section
7'700 of Ne labor Code,fm Nn pato.cohc work for which this permit Is Woed. -
My Work, fWJpBlsaae curia and Polic
Carier:...L141/C/�L///// Policy Noy nu.: ODIOI
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
or al
(This son cad tw becomphoal ifNmi
e pn t is for..hundred dWleas($100)
'
1 certify that in the let-,.note work for which this peoo is iaued.I abut
no employ any press.to any manor M u h,,came abject in Ne Workers'Compco-
arion Law,of Celifomia.Dau -
Applicant
NOTICE TO APPLICANT:If.afar making this Certifiare Of Eaempdon,you sWuld
hecomc subject to the Workalt Contpenation provisions of th<LOW,Cade,you at
forthwith comply with such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
0 0 l hereby affirm lhu there is a consracuon lending agency for the peRomuae of
the work for which Nir pencil is toned(Sec.3097,Civ.C.)
E. Undoes Nemo
a } Landefs Addrex
Q1 certify Nn 1 have mad this application and arm,Nat the above inforowia is
a z conal rn
1 ag.to mply with ity all cand county ordinance,cad than,laws mlot,an
t.7 O Wilding c«uamction,and herebyeuNoda rtprtsena,ova of Nis city toenur upon ft
ebovcmemioned Property for Inspection Proposes.
:z' tr (We)agree m nave,indemnify and kap hamdea the Clry of Cupertino against
0 C.) bah"fin,juEgmu
cn ,eau and expsema
nna which y in any way ucroe shuns,and City
} GT: in crosequence of the gandng of 's permit.
r APPLICANT UNDEI A ANDWII.L COMPLY WITH ALL NON-POINT
V z SOURCE REGIfiJiTIOPPr
SigvmrtofA J omnmor Due '
RDOUS MATERIALS DISCLOSURE -
W111,hee tafumnWildingoncupanlalonarhasWeharallousmalerial Re-roofs
u deGvd by the upestino Municipal Code,Chapter 9.13,sed the Health and Safety
Code,Section 25532(11)+ Type of Roof'
Yes JN.
Will the applicant or future Wilding occupam use equipment or devices which All roofs shall be inspected prior to any roofing material being
Md'havankno air contamivnts as defined by he Bay Arca Ah Qwliry,Management installed. If a roof is installed without first obtaining an inspection
NoDl,umt7 I a ree to remove all new materials for inspection. Applicant i
❑Yes g
IluverW Ne huudwa meta-l-gWl ..n rChapra6.95of Ih CW- Understands and will c triply with all non point source regulations.
rani,Webb R Safety Code,Sadnnr 25505.25533 and 25530.1 orde,aund Net if the
Funding does no cuoemly have Innen,Net it is my rca,nslbiliryana'yNe occupant
of Nc reyuirtm u which mu a met pro«to urnaoee of•CO,d p9�� C./
Dwnera,ro. gent — nine Signature of ca Date
All roof coverings to be Class"B"or better
OFFICE