00030141 (2) ." :CITY OF CUPERTINO - - - PERMIT NO.BUILDING DIVISION PERMIT `' ° ° it I I
BUILDING ADDRESS ...Y,f; r x �//� Thi•.
•, S - ^SANITARY NO. APPLICATION SUBMITTAL DATE
� ,GEAR N 2 —
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OWNER'S NAME: - / L N .f,�. 7 '
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�.( YJI. - N/C r - CONTROL#IONE . .
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ARCHITECTMNGINEER - t
J ar•c-n
F
z, LICENSED CONTRACTORS DECLARATION
o I hereby affirmthat 1 sm licensed under provisions of Chapter 9(commencing - Job Deseription` ,
F m with Section 7")sanDivi.i.3-frhe Buslrses, it Professions Code,and my license is _
4y -1'.' in Poll fame and efiea
(p e:Z7$.S' •, ,
L 3 F
Data
wClesv Conwcwr I
/,7c/ s. �2eisx�p ?
+^ a cxlTecrgnec a o
5 w�,� 1 understvld my plans,shall be used as public mcada r -
ti o Licensed professional
OWNER-BUILDER DECLARATION.'
C G F 1 hereby affirm that I and exempt from the Contraccor's License Law for the _
5 A following reason (Section M31.5.Business and Professions Cade My city or county-
i5 m which req nes a permit to conswcr shot,improve demolish,or repair ar swemrc S Ft:Floor. Valuation
prim to't ' ante also resume the applicant forsuch pemu,mfl signed statement' (I-
,Ilan he.licensed W ant in the provisions of Ne Conrtacmrs Liar Iaw(Chapter 9
(commencing with Section]0)Hycd Di,hiim2 ofrhe Business and pro(essswsCade)or -this,he 1,exempt dowfirmn and the boob for the alleged examptian.An, maitre e a PNumber Occupancy Type
Section 7031.5 by any applicant for a pem,ii subjects,W applicant to a civil penalty of A'.
not more than five hundred dollars(S500).
I,as owner o(de progeny.or my employn�with wages as thcinolc compenssuon. Required InspectlOns,
will do Ne work,mrd the auumurc is not intendedaroRerM(m sale(Sec.7014,Business '
sid Professions Cade:The Contractor's License taw don not apply to an owner a ' '
property who builds or improves,hereon.and who d«s such work himself or throgh
uV'Jv
_ his own employees,Provided that such improvements tie not imm.ded m offered for -
sale.If.however,the Wilding car improvement is sold wi,hinane yearofcompledoq the -
owror-Wilder will have the burden of proving the he did not build or improve for Pur-
' pore ofowe) s .. .
Q I as owns f the property and cl lively oats tig with 1..nand rintim ed
'constraat the p., ,(Sa's]044 B eve a d Profauo a Cod )Th Co met s U - - -
ter
Lewd p aha hoof pr party h builds pr vbe thereon and
who
- r
-who onwsuch
contracts for cM1 proj owrth ecommands)licensed pursuantm Ne ContnctWe
Lice law. ..
❑1 mon exempt under Sec - B&P C fo/thn
Owner s Date '- l! / ! -•
WORKERS COMPENSATION DECLARATION -
Ihercbyaffiw derpenWyof aCononeofcif-in owmgdedare.Co. O '
Ihave and Provided
for by
e3i7W of But
to self-imumfm Workers Ge op en a - '
tion,as which this
for mi Ss issued.3]00 of the labor Code,fire the peAowantt of Ne
w3fI for and thus annu a orbas . s '
E!1 have and will rosinedn W pe ffu Circe m such Irk for h his p d by Section "
'MY or, LaborCak,fmthe perfsxmaree ofrhewmk for which this permit is -
MyWorkersCompenaetio�s lneurmoe camaelt Polo
Cartier G LJi AID Policy No.:
ERTIFI—eCATE OF EXEMPTION FROM WOR�g' •t
COMPENSATION INSURANCE -
(This action need not completed lfthe pewit is forme hundred dollars(SI00)
in less)
.Ianifytlutin,heperfmmancear Newmkforwhich,Mlpemdtisismed,lshall - o -
not employ any Person in any manor so as to become od ecr tp the Workers'Compen-
safon Laws of California.Date
Applicant •. - q
NOTICE TO APPLICANII If,after marring this Cmti&are of Exemption,you should
become subject to the Workers Cosnpenisn"provisions of the Labor Cade,you must ,r
fonhwiN comply with such provisions or this Permit shall W do mrol revoked. ., . .
CONSTRUON LENDING AGENCY,
�'p CHI hereby affirm Nm them is a comuwfthm lending agency for the performmme of r
the wok for
which Nis pewit is issued(Sec.lig],Civ.C.) -
[r nil Lenders Name
Dander,Address r, * ^
teeegr�... A 1 certify dim I have read this application and mile that the above formation is -
U O conal)I agree to comply-with all city and cosset'odimncn and uta laws saluting to
building conawction.'and hereby allomire rcpreservatives of th' ity or enter upon the
shove msmumead property for inspection porpoaev' _ s 1-
W t.,a (We)agree rte save,indemnify and kap harmless the City of Cupertino against
C'(J liabilities,judgments,costs and expenses which may in any way acme against said City
;a Win con equmse of the granting of this permit.
tAPPLICANT UNDERSTANDS'AND WILL COMPLY WITH ALL NON-MINT , ,1 y
SOURCE REGULATIONS. a � -
Sgnmuse.1 A ptpticunOConractm �tC Dao-
HAZARDOUS MATERIALS DISCLOSURE
Will this.,Iicam or fuom Wilding occupant store or hariNe hmadous noomf Re-roofs v
as defined by the(2uperneMunicipal Code,Chapter 9.12,and the Health and Safety 1 ^
.Cade,Section 2e532(a)1 t" - Type of Roof '
E]Yet. No r
Will rive,amlicantorfuture Wildingoccupantuse equipmentordevice,which s All roofs shall'be inspected prior to an roofing material being'• .
rot baccdoa,air Wnum t as defend byth Bay Meng G ality Management installed: If a roof is Installed without first obtaining an inspection
um, I a ree to remove,all new materials for inspection. Applicant .
❑Yes No I 1 1 g
Ihaw read the hreardwswodalsesuu ouuderCWpha695afda,Cd understands and-will comply with'all^non pomtsouree regulations.'
Ionia Health At Safety Cade Section 25505 25533 and 25534.1 undosond that if the , t
building does ria cummily have s lana.,Nott is my emsursnbdi1,rte unify the occupant s
of rbc m wNch mut met prior to usuwce of a Certificate of Occupancy C ° '
mrcme s
.?!pQa-00 Signature of Applicant Date
u gent Dao. 1 '
All roof coverings to lie Class'Brr or better `
OFFICE