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00050105 (2) C ITY OF CUPERTINO - < ^ . BUILDING DIVISION' - PERMIT ON .I Ph1F FTI p ( 'PERMIT NO., •- ILDING ADDRESS: 05 S � �ss �x SANITARY NO. APPLICATION SUBMITTAL DATI NIC .. CONTROLkCHITECT'/ENGINP.ER I.ICENSEDCONTRACTORSDECLARADON - oz= 'Job Description ' rryt:.� ween Sectio]000)ofDnvisioe3of CeBmmcnsand Dotueiom Code,aM mylicenae •,• - _ c < In full farce and effect /7 t 5SqS ' stases C1 1--, ��Lic.N.. 6 -toa I ARCHITECTS DECLARATION 1 undennod my Plans shall be used is public rewNs a a o a Uoemed Professional uaS OWNER"BUBDER DLA ECRAI'ION •• " 6 I hereby affirm am I that I exempt f Ne Contactor' LiceLicart.Law for the - F O following reawn (Stetson 7031 S,Business and Prifoeton3 Code My city or court, _ 3 which segmres a remain in construct,alter,improve demolish or reps r any stmentre ,S Ft.1^"1007 Area.-, Valuation prior to its Issuance also agmres the applicant foreuch permit W Bleaslimed statement q• n ' ,shat he is licensed puauanl to the pmlilim of In.Cwntradors License La (Chapter 9� " (commencing wish Section 7000)of Division 3 afthe Business wad Professions Cartel or APN Number,•Nal he is exempt therefrom and the basis far me alleged exemption.Any violadan of ri Occupancy Type Section 7031.5 by my applicant for a permit subjects die applicant to a civil penalty of not more man five hundred dollars 0 Las owner offlee property.or my amployinns with wages a their sole compareation, " 'Required Inspect'to will dome work,and theshtrcere Isnot Intended mothered forsake(Sec,7044,Business - and Professions Code The Contractors License Law docs nm apply m an owner a ' - prapcny who builds or Improves thereon,and who dues such wask himself or through It his own employees provided dui such Improvemenu are not intended as offered far - sale.If,however,thebuiltling or improvement is said widen aIle yevofcompletian,rhe, ' e owner- w'1 - buidtt will basic Nc burden of previous Nat he did not r v ' Wild ion'ro a for u P vie 0 Pr- •w�/ ❑1,as owner of the Property,runBusiness s any contracting CwishW:[shedoma m news she project(Sec 7014 erofsed property whoProfession;Code)Thes.thecrom 1", cense Isco dies not applyje ts owner of progeny who builds or imptuvee Corton and - /O whocontraw,for each Pro3eca with iconuacrogO hcenad punuant m'he Contredors ' License Uw. '�' ❑lamexemptunda Sec v ,B R PCfarmi3 icadri Owner Date CR' WORKER'S COMPENSATION DECT"AMTION 1 hereby Mrd under Frosty of perjury one of me following declamima: ❑Ihwvcualwillmeinsn a Ccrrifiwaaf Consmttowlf.insumfor WmkesCompn- s at on,a provided fm by Recd n 3700 of the Labor Code,fin the perfomunce of the . coo for which this permout is issued. I have and will maintain Workers Compensation Insurance,as required by Section of the LaborCode,for drc do... of me work for whish this penmduusued. l � " •s My Wotker s re a man unce carrier d Policy Ratio, t Gao, j _Policy No , CERTIFICATE OF EnMPCION FROM WORKERS COMPENSATION INSURANCE .(Thi sermon aced nil be comPleredifthc pcmutm flea ehundrtd dollen($100) ry - , 1 erify matin the perfonnanccofinewmk Por which th apemuuaiaued,I;hall ' not employ any scrern m my manner so ss to become subject to die WmkyrR Compsn- • _ Ration Uws of Califomia.Dass Applicant - .. N(mCE TO APPLICANT If,after making this Certificate of Exemption,you should s become subject'.me Workers Compensation provisions of me labor Cade,you must - - fonhwim comply with such provimmus or this permit shall w dearest revoked. ._ CONSTRUCTION LENDING AGENCY' 0 I beabY eRrsn mal mem u e wnswcuan leMmg agency(.ribs pcdotmancc of the work for which this permit Is issued(Sec.3097,Civ.C.) " F., Ureters Name # •(yet, Under;Address - - W.Q 1 cerdfy slier 1 have read this application and ante that me above information is r+ O carrcct comply me agree to comwith all city wird coney ordinances and are laws rele4ng to b , y a ,ng commission.and hereby authmis repre;enutives.0thri try to amesti'm mer above mentioned property for ine,satim,purposes. _ C) i. (W ec m save I unity and keep harmless the City of Cupertino against' , Q V lubib- judg nu,case deeps as wti Amey in wry wa waeagaimt said City >r W in sequence me ung of m'3 perm As , ��� code PLICANTU . 5 NDSAND MPLY 0 _P0 • t ., ` f..) U "EREGU TIO ' . 17 6 Pelican o tot are •.''� t�L s �/' V •�D v I HAZARDOUS MATERIALS DISCLOSURE Will me applicant or future building occupant store atheistic haedous material ,Re-rOOfs, - m defined by the Cupenino Municipal Code.Chapter 9.12:eM Ce Hess and Safety ' - Cadr,sectum25532(r)7 Type of Roof - ❑Yes ON. _ Will thea,,licanterfuture Wilding occup:tuserga;Pmeardevices wash All roofs.shall be inspected'prib'r to any roofing, material being emit ha�rR doax. conaminann as defined by the Bay Area.Air Quality Management installed.If aloof is Installed without first obtaining.an inspection Diatra No .ic'7 La tee to remove all,now materials for inspection. Applicant - ❑ g Ili., androeh asmutedY;nnidtj ttatthe cdi. understands and will comply with all non point source regulations. fmnn Hwlm Safety Sections 25W5,2333x3d met if me " bdldtng dao t1Y yf ¢nam Omnis cu t me u I a6yl C�-npri lo' Ce (/V Signature of Applicant Date mmiaea agent 'Does' + _ (. ) , ' " - All roof coverings to be Class"B"or better