00030209 (2) CITY OF CUPERTINOPeRMrrNO
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BUILDING DIVISION PERMIT . COO NTI�%AfCT®R IIO +MA�TI b ' • 0C2�5,1:;> I//
BUI�LyDINGADDRESS /� �/y oo
QCOO tSO. BL �. HU I Y�QQ O/� Ss�—I,�✓/COS�/,/g�� SANITARY NO. AICA 5 AL DATE
OWNER'. N M Oayl i �K1/��I X/r/VC
/��( V&KG �/}� / ���5 NIC CONTROLN
1'110NC: �40— —�✓`! G, ❑ s � ..
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AIiCHiTECT/ENGINEFR , � DUEI{GLI)IN071'ERMITfIN,
50c , 2/y- 3 s7( - 3,66q
6 N
Z FO v>toi i LICENSED CONTRACTOR'S DECLARATION _
O Z_ I hereby affirm the 1 am limented under provisions of Chapter 9(commencing Job Description
p,_n f-.tri with gation]000)eDivisim Sofdre Business and Profmium Code.ad my hum.is
y J in full form resource.
a < Ucene Class Li,0
3 u Date' • P/'' n, �• /�� /f /}/� J/��_��,� R /��/_"1.Ir .
ARC Contractor
ndeDECLARATION s .. /�J ��I/vrG L ' (i(/I/"O!/W�"�--/� LAf�'G/✓I"'
fft0 nund 1 m sd u public rtwNs
a E fe m rd r
ha1 V -
OWNER-BUILDER CI. RATION
C Z r 1 hen a od,that 1 sat exempt from the Convec o',Licence Law for the
I x O following rt (SMi.n 7031.5.Business and Professions Cade:Any city a wunry
W w "which reqs; a Permit m comments,alar,improrc,demolish,or repair avy,stractum
a_ Sy. FL Floor Area ' V luation �i,l�
Prior 10 its em..a,alsorequire.the applicant fermth permit w file a aili dmacrecns -
that he is licaremd po suint tithe provisions of the Connector.U..taw(Chapter 9
(commencing with Section 7")of Division 3 ofthe Business;and Professional Cools)or
NN Number � T at he is exempt therefrom aM t e basin for me alleged exemption.Any violation teenenc of r Occupancy Type
Section 7031.5 by any applicant her Permit v peit subjects the applicamno a civil Family of
naw more than five hundred dollen(5500).
❑l,mowner.rda,pr.party.or my employees wiNwages asdenoted. mmpetemmi, ) - - Required Inspections '
will doth.workmd Neamuctun;.not lm6dedwo6ered formk(Sec.7W,Buaineu
end Pmf.,smus Code:The Contractors License Lew does not apply to ver owner a
property who builds or improves thertnn;and who does such work himself of through
hie own employees,provided Net such improvements art not intended or.Berta for -
sale.If.however,me building or improvement la sold within one yes.of compleuoo.the -
woer-builder will have the ban en of prevent that he did naw build or improve for par,
pore of se ��
❑ nore thm of de praperry,am eaclusivelY cono-ac4n8 with littnscd convamn to
tom=ato does
jepplyin an Bainessmpey.1 bus Code:)The Convectors V. /
whocan=
contracts
f me moth
to an idea of progeny w W builds w improve Conoco and /who cunnsuts far such palati with a rontnnady licensed pursuanuo Ne Conoecton
Licenm Law. _ O
❑lam exempt antler Sa. ,B&PCfor Nis xenon _ - • (/1 '
Owner °ate • ' �•/
WORKER'S COMPENSATION DECLARATION -
f hereby aRrm under pa n s"of perjury rave of me fallowing dalaratiom:
❑I lime and will mshossm a Cst ificme ofConarnuo self-insum for Worheb Compem
saoion.m provided fw by Salon 3]00 of Ne Labor Code,for the perfomana of Ne '
work for wn)iI ii wed.
�11�1
I havee -6uin Compenntion Immnvice.u nquved by section
,fordm peeve pp of theworkfor which Nis permit is issued.an 1enraect hr mtl Policy number an:
ayATEOF e%eMPn OM WORKERS'
COMPENSATION SURANCE
mued n.tbecorepletelif parmalisfaromhundrWdollera(5100)or less.) ,Icethe performance of me work for which this pemdt i.issued,l shopnot employmy manner so a to become.onmt to the Workers Compcn- le .
nation Law,of California.Dan
Applicant
NOTICE TO APPLICANT:IE after normal this Cal ifcate of Exemption,you should
berm.sub)at w the Workers Compemnion provisions of dee labor Code,you
forthwith comply wide such provisions or this Inmith shall thedamed revoked. '
CONSTRUCTION LENDING AGENCY
0 I hereby affirm mat time is ecoatrucuon kruingageay for the perfomumaof -
.Zr h the work for which this permit is issued(Sm.3097,Civ.C.) _
.t••s r I.enders Name .
Lenders Address
WI 1 certify,that I hale read this application and state that the above iref emotion is s '
Css Qcorrect.I agree a comply wit all city and county ordinances arta sure laws relating to .
U O building conservation,and hereby authoda repnnnmivm of this city to enter upon the •
surnwoundmild pmpany for inspection purposes.
L4 tor'. (We).tree no save.imbrowfy and kap harmless the City of Cupertino against -
0 U liahilides,judgments.curs and expenses which may in my way amme,some mid City -
�, W in conaequeme of the granting of this permit.
Fe y APPLICANI' FRSTAN ., WITH ALL INT - '
IATIONS.'
coma.AppliunJC tat Date
RDODS MATERIALS CLOSURE
Will theapplic mor fm as Wildintacu tsmmorbmaLolus."ousmetedal Re-roofs.
as defined by the C Wino Municipal C epos 9.12,and the Health and Safety
Conic;Section 25532(.) Type of Roof -
❑Va ❑
Will the applicant or fuura Wilding oompant rpmem or device.which All roofs shall be inspected prior to any roofing material being
emit hsramdom air conumi to as definedb yArea Air QWiry Mmetemem installed. If a roof is Installed without first obtaining an inspection
Distract? �— I agree to remove all new materials for inspection. Applicant
J ❑Yes d
un g ersta and will com all no point source regulations.
1 Mme red the hsmrdan materials nyuiremenu abler Chapter 6.95 of the Cash.
hunts Healm&Safety Code,Sections 25505.35533 and 25530.1 understand mer if Ne
Fuildingdoes not monetary have a atom,Net it is my responsibility to manly the oecupmt
of the nqummeanu which must ba met prior to issuance of a Certificate M Oomplerwy
ig tare of Apple ' Date
Owners authorized agent Dan
All roof cove ngs to be Class"B"or better
OFFICE