00040160 (2) - CITY OF CUPERTINO' ,. PERMIT NO., ' .
smtnwcmvrslov PERMIT,'
CONTRACTOR INFORMATION:
-- BUILDING ADDRESS. ./�a 1 (� - _ `- ,•�s� - '
I,NQ\ .v•SANf1AIN No. ' AVVLICAIIQNSUBMITTALDATE
OWNER NAME' •^�AaL �t[A '
ar, n'q��+,�r,'�.y�' e I a, NIC - y CONTROL# r
PON' Ae
- �GNo'lP � `ORI1 .—t,x.c�0 »: ❑ t , J
ARCHITECT/LNGINEER - \ INDQ BULUINC PERMIT INTO
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LICENSED CONTRACTORS DECLARATION
ZOO G 1 hereby affirm that 1'am I ased W P on f CM1apt 9(comment g ^r -Job Description'
F5; wiNSauon]000)°fD/Jfga 3mf me Beene a/nil Peof/e a'ta]roCWe and mylice Lipa �p y� � y��
-re'zNQ
in full force uW effect /V /7�LL7� �f e1�C- .�/ « Y1. _[WK�Id ' `l-i,Yl1
3 u, Liu a las Lic D •�^ +
a N Dat convector
t... v, As that WCT$DECLARATION ,d .:iQ�_I dry,171
NSN I de mM y plans shall be used public and jg/��5..�'�q� 1� ,'`a•4J 1 (•�6 'Vt :
a` gWWLS Q >
a'�°��,5 I`LcensW Pmfeasional - r . M :4/t
OWNER-BUILDER DECLARATION, , -
5 3'6 •J hereby arctm that L sin exempt from Ne Contra I e We vise Law for the9 � A*
0 followsmg reason.(Section 7031.5.Business and Profusions Cad Any city or..atyc. : «
c.❑ which set 'sea a Factor m cum meal Wer Improve demolish,ar mpmr say rtmcnue -
3_ Sq. Ft. Floor Area Valuation
prior t.its ixmanee.also mgmims Ne apphumfonuch I.o`fileengoed stem rnt �a
mat M1e is licensed pursuanuo Ne proviai.m ofine Coons<tota Licemaelaw(Chapter9 i e C '- .2 aQV
(cam a is exempt therefrom
]OOd th basis f r roti egedeasaW on.A y inaction of APN Number , Occupancy Type.
'Natio Is exempt therefrom and me buti f the Urged axe a - Any violation of p y yp
Section mu S,eany dead,pliccumd.11 fora penin t subj t the applicant m e civil penilry of
not more Nen fve hundred dalary(550)), .
❑laeowner.rmepropenr.wmremPloyeeewimwageaesmeir.olewmpensaman., '� Requiredinspections ,
will do Ne work,and RtesBucmre is not intandedmufferel for salc(See 9044,Business - _Y
,,ad Profaaiom Code:The Contrition Liumom Law docs not apply,to an owner of
property who builds or improves,thereon,fed who does such work himself or mmugh
his own mr I.,scs,provided unit such improvements sin via intended or offered for a�
r sale If,however the building.,imprevemenus sold haircuts yearrakiiin,latimi.the - f -
ncr Wilder will have Ns burden of proving that he did rot build or improve far Pur. a'
° P"4
pose of sale) ,
construct
o 1 ee ower of the pcpeny,am exclusively confessions Cole:)
ol 1t eased conmouns i -
verneLctmepronto(Sec ]DI4 owner
of
professionsul Cede)These nhenof la L
sc Law does rnot,tichapply je m ower of propury who bio Ids p mere. and
Licem,Law.for such proleetsw Nec 'n nuHq bcensed puss sort Ne Convectors
- Gcansa law.
' C In nde,S Bk PC formia -
.. Dartn
WORKER'S COMPENSATION DECLARATION r roes --
lhcmbyeffirm nder`pemaltyofpsrjuOy ofine following declarafmu^ - f (:+• n,'ns t 1 '
El I have and will maintain a Certificate of CmrsenooselRsnsurefor WorkersCompen.
sauon,as provided for mi Storm,3]00 of the labor Cads,for the performance of M r
It
w for which rots permit ts issued.
� - 1
I have and will maintain hepedWorker's Coma afdt an Insurance.h required by Section
of me labor Castle,for me Aormance ofine work for which this ,mit isiea cd.
ps f 't
My Wur anlnimanu curie,kad Policy 3 ` s
PrAic,
TW
CERTIFICATE OFSATION1INN FROM RKERS '
COMPENSATION INSURANCE _ f � I tY
(Th u nneW rbc pleted'fm Perrot shot on h rimed dollars lS100) r '
ail ) .. „,. ♦ .t
Ioyany lasomtne pert uweofm kfrwhmh,M1rpe,W es'Co. all
.-
mt employ any penun'is any manner so as to bcc .mbleet w me Worker%Compen- f
-sauon Laws of Celi(omiu Dem c t ' t i
.'Applicant
NOTICE TO APPLICANT If,after mala mf
g 's Certificate f Exempuan you should a '
become subject to thaWmIcee.Compensation Provisions of Ns labor Code,youmust t ,
_
r
fonhwiN comply with such provisions or this parrots shell h domed revoked. '
z
CONSTRUCTION LENDING AGENCY
Q Ifor whifhthi perm 'issued swc.3 len ding agency fonhe performance of , +
r•a Le work for which this perm us issued(Sec.3W7,Civ.C) _ „ c `
LaWeraAdjo e _ , _ °t
Iandcrs Addro[a �r� r,�'
I cenify that I have reed this application and subc that the above infommtion is
L
,Z coisect,l agree to comply w m all city and c msy xfi maces and feu laws relarng I.
Ll
building construction, auprc
and hereby authoreenmfves ofthsctyl enter upon me
'V ruabo isina Limned property for ms,acoan purposes.
Taw+[a (W).9.me mdformfy dkeep harmless does City of Cupertino against t `
babl'i 'jdgmems,coatsindeaprewas which may namyweyaccmeagumst said City -
�r W, mconequeneeofthegmmnng of Ni cermis. i• - +• ,
O+ APPLICANT UNDER STANDS WILL COMPLY WITH ALL NON-POINT
r
SOi 'RECU ATION ,
U z ,. f�����
^' Signatu m`Appli.,rC.nb�tror , 'Date �i.: �/ ��/ /,_',. .. • '%
HAZARDOUS MATERIALS DISCLOSURE II/
WIINeappli6mtorfummhildingbccuputstomorhanmehue ousmamnal R6-roofs f i
sw defined by the Cupertm.Municipal Code,Chapter 9 12,and the Heeltt,aiid'Safety i
Code,Section 25532R)? ��• 'Type of Roof
a +. .y WIINe ppl;ca t fumrcbuldingoccup tuseequpment 'devices wheh All roofs shall be inspeeted�prior to any',;roofing•material being
routhmatc,linissarcontarmatntaa fined byte B yAreaA 0 ally Manage emr installed. If a-roof is installed without firsf obiatning an inspection
District? I agree to'rerriove all new materials for inspection. Applicant.
❑Yes No d -+
U n erstands an it co p1jl with non point source regpulations.'
I he a read m h nerd mnerialr talc meats under C'h purr 695 of me CW t C' Y C
humin Health A Safety Code Sepk1oms 25505 S5t3 end 259341 Inderstm: that 11 me
build' does oic tlYh .)bWt ant Nat s myrespo 'blty to notify upnot
o y
t be [ ofa Cerffc e f \ s ^/ir' "� "` f r•'
Signature of Applicant' a " Date
w ownerorauthonom.ge t am :! ' f ': .c '
.r 'All roof coverings to be Class"B'l-or'better.
OFFICE .