00020064 (2) CITY OF CUPERTINO PERMIT No.
OR"INFORMATIONSBUIL INcDIVISION CONTRT
a, QQO2 O
PERMIT
BUILDING ADDRESS:Q °
�+ d. n - � _ SANITARY NO. ' APPLICATION SUBMITTAL DATE
U d P-1'C_J
OWNER'S AM@ - N/C f.CONTROLto
q
ONE: 1��.I `�+ , ❑
ARCl MITECT/ENGINEER futbiN PERMtr MIB
6
Z O?z LICENSED CONTRACTOR'S DECLARATION
O Z_ I hereby all=dust I em licensed under provisions of Chapter 9(mmmercivg , Job Descriptio
(=� with Section 7000)ombvision 3 ofNe Business and Pretentious Code.aMmy liana is
6 Y f in full face and effect. ,
0aClue .M
i 1, DaDeae /��• - f
3 a Data—C
ARCHITECT'S
Lu O¢ 'S DECLARATION ARATION
v�i J 1 undenmd mY Plans slWl M thud u Public records " ,
ddd��Qp
o License professional r a
OWNER exempt Fr DECLARATION
barely�'>�< • Ibarely.(Sinn Nexempt
am
at I from the
s�w ComLaw for the
Ofollowing ew.($cnio0313.Bananas end Profwimis Cods:A,city
'
a aunty s
d 3F win`""y"'m'a par"'i'to`°""n'a'.Ile'•impm"e•d`"'°'i`h•°".pair°ny"n"°°< Sq. Ft.Floor Area - Valuation
prion to its issuance,also requires the applicant forsuch permit to flow sutement
Nat he is licenudpunuant to Ne provisions of OS Crnaztore Licrnulaw(Clspta9 '
to,he is itumps d aeon 7000)mr,bassimr the a cpd cloopt m,Any
vi Codd or APN Number ' -Oe ane Type fro he is campy thmafrom and the basis far be alleged exeapnm.Any violation of y yp
nation 703 LS by any applicant doll fora permit subjects the applicant a civil penalty of pre o
-
no mom Nen five hundred dollen($300). � - -
❑I,as owner of Ne propeny,a my ampinyas witA wages u dseirvolo mmpenaation, Required Inspections
W Professions
Mede oContianai Lemnos
apply toanromra '
W property
who
Cods:The vs dream Liana Saw dela wells•PWY to.Armorgh
his own wW builds or aided th thereon,and who dons inch e deed or f through
his own employers,provided thro such improvements ere not intended a offered for -
uln.l brildeur,Nhave,dingaimpmprovir issoldhe id am yevof provetiomthe
owneoW ileer will has the burden of provin6 that he did non Wild.,improve for pa.
ppoauer�fyI6e
[}f.'G—w r of t s property,am exclusively consulting with licensed mountains ter"
lease La the es net appl(Smy
?miss,Busowner
of rote property
whoWilds
Code:)The Conuazmh Lid
who
contracts
ones net apply m u owner.(progeny who Wilda a improves Camon,std -
whoconoactsfor ash projas wiNacootnnodq licensed payment to Ne Contmctote t
Litems Law. - - �j0
El leatormi Wer,Son. ,B RPC formia -
Owner Des u -
WORKER'SCOMP SATION TON
1 nf
y a0ir ander Faulty of Pa jury one the following declarations:
I have and will maintain a Certificate aconsrnuo anif.m me for Work"'.Comport-
tion,as Provided for by Saxon 3700 of the Labor Code,for the perfomunm of the
work for which tis permit is issud.
❑I have and will maintain Wnrtet's Compmox lon Immure,or required by Section .
3700of me Libor Cade.fur she p ufa rang of the work for which this permit is issued,
My Workers Compensation[a..carrier and Policy number am:
Curia: Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE '
(This mesion need nes W er mPletd if the Palms is for one hondrd dollar($100)
or less.)
I minify that in the performce of the work for which this peril is issued.Ishii
not employ any person in ay manner so as m become vubjeet to the Workers'Couple. ' -
va inn Laws of California.Date .
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to to Workces Compensation provisions of the Labor Code.yin must
. forthwith mmply wit such provisions or this Permit shall be darned revoked.
0 Q CONSTRUCTION LENDING AGENCY
Ihereby attarthe Neu isa mmtrucdon lending agency for the performance of ' -
Z r the work for which this
perm ie ni ud(Sec.3097,Civ C.) ,
Lendels Name _ -
'!,4 F'n Lender's Address
{i� I certify is 1 have lead Nilly and Won the esu that the above laws
scha on is
a.Q burin I ague ct comply with y city and counts mdm.ncof this awe laws relating s,
.� z buildingcmonod pro and hortbyamhonurepaunutives of this city to enter upon the
V above-memired property for inspection pu
W F (We)agree l,leve,indemnify sad keepcep haha
rness the City of ti amno.damn
V inconsm judgmentse losses ad expenses which may in ay way same egsinxt aid City '
in consequence of theN of this peril. - -
F� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNON-POINT _
V � SOURCE.REGULATIONS.
Signatuuof Applicant/Comrmuor Das'1
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or form Wilding acupent stare or handle hieadous material Re-roofs
as defined by the Cupertino Municipal Cali,Chapter 9.12,and the Heath and Safety
Code,SnoWn 25532(°)+ Type of Roof
❑Yes [I No
Will tc applicant or future building occasional use equipment or devices which All roofs shall be inspected prior to any roofing material being.
mit haardoux ea consminanu as defirrcd by the Bay Arte Ah.Queliry Management installed. If a roof is installed without'first obtaining an inspection
"""'
❑ I agree to remove all new materials for inspection. Applicant
Yes ON. ''
I have ted Ne ha dn mmasomis rtgaimmmlts under Chapter 6.95°fro cof- unerstands and will comply with all non point source regulations.
fomu Health At Safety Cade,Sections 23505,25333 and 25530.1 understand Out if the
building dons nes currently have a tenant.Nm it is my responsibility to naify Ne emuparn
of the syuuemenn which must be innpiionmusuthme ofa Certificate o(Occupancy. -
Signature of Applicant Date
Ownerm eatanledagree Dam ..
All roof coverings to be Class"B"or better
OFFICE