00050131 (2) CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERMIT COO NTRACT [OR INF IOR+MAITIQ. c
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a 1 - - SANITARYNO. APTIONS MITTAL)ATI
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^F. 'S NAME: /yy'
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ARCHITECr/F,NGINEER —r�L�O��s BULTDIN ;PLR'MITrIN[p
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o— I hereby.Brtmdeale"fetteed under wdsiau ger Clupdt
ee.ru9oedpwihS, dmY littnw is -
JQob Description full forcead ellen.
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3 ' D^rc Conovclor
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u G S DECLAR.NTION
I undetetaM my Near-hall beLurgd u pall""records, '
o Ucrnaed Roksemnel _ _ '
u� OWNBR egarpt foDECLARATION f
C?< 1 hereby effort an 1 am eacmpl fma Ne COngrnslCod License Law o for the
I F❑ following mgs°n. cm lion]OJLS. L ghg,a and Professions Cade:Any city o county
which rcquim,a permit to wmwcg,altar,impO.o,demolit,or repair any swcmrc $ Ft.Floor Area
pnorto iu is,wlra,alw requirtsthe applicrntfor ouch permit afleasignedaatemwt q' ® Valuation
Net M1e iv licenud punumtwthe provisions of the Contraclore Licrna Law(Chapmr9 - eery
(C°iMICK1Og WIB1$SdOn]ggB)Of D1VIxlOn3of BIC BY-Inba Md Pw(e{6lonv l.'ade)Or V
than he is exempt thetefmm grated the basis for the alleged exemption.My violation of l APN urnbe r I Occupancy Type
Section 7031.5 by any epplicaat fine pemtil subjects the applicant to a civil penalty of (D _
not mom then Eve hafted dollen(S500). -
'❑I,ax°"""°rN`p°p"'y'°`my`mpl°yec'wilh w'ge'um`i...lecompanvnion, equired Inspections
willdothework.end the,Imcwrcia era inaldedoroHea4 for sale(SaA04q,Basin<u "
end Profe-slom Code:The Corea".Lianas law doe,Tal apply to m own,M r -
property who Wild,or impact'.thereon,and Who does.such wpk himself ot through
his own employees,provided 1ha,such improvar ,a r,ve not intetded or ofitted for
sale.If,however.the building or improvement is within one yes of compilation,the
owrcr-leahkc will have da Wrden of paving Net W did nal Wild or improve for For. v
of
Q h u owner of the property,-m esduelvely contracting wit licensed conlracw,s to , , -
co suua the projwt(Sec.](,eg,Business sand profood.Code:)I,Contractor,U.
cense law does an apply to an owns of PwPeny-W Wilds in,improves thereon,end
whowntrade fonuchpmjecuwi ggramctrplic gap ursuam a Ne Contractors
License Gro.
dame .B&PCf.th+srt n .
arc
WORT 'SCOMP SATIONDECLARATION Q -
Iherebyalfirmu derpenWy perjury ale Ofthe following declasati0
❑--ave Sud will mail naina Cenif& m fCauemawl6immol "Workers COmpero '
urian,as Provided for by Section 3]00 of the LeWr Cade,for the performance of hie _ -
work for which this permit is issued.
❑1 have gnd will Mman Waste Conipmearoon Insurer,u requhW by Section
MYW.1te.Co Code,folieperformanceof thinworkforwhich this Permit issued.
My Workers Camcrode.on hs cont crena and Policy numbtt em: -
Cartier: Policy NO.:
CERTIFICATE OF E3CEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(This need not W completed iftha peau is rmonehunthml dollars(SIM)
or lung.)
I oy my that in the my manner$0 tewak for which this permit is issued,i slet-
sot employ any alike in any manner v°as to become mbjecna to W°I*eri COmpen-
Appliawe of Cfifomia Dale `
Applicmt
NOTICE To APPLICANT:If,afar melting this Certificate of Esampdon,you should
become Subject to the Workda Compensation provisions of the labor Cade.you men
'foMwith comply with such provisions or this fumit ehall W deemed euvoked.
CONSTRUCTION LENDING AGENCY
z 2 I hereby aRrm that Nem is a construction lending agency for the parfomunce of
z inn+ to work for which this Permit is issued(Sm.W.Civ,C.)
y lenders Name
(yl' > Lender's Ackrera
L0 I canal?Net I have raged this epp-ication and sae Nat the above information is a correct.l boom to comply with ell city and county ofilunw,god Rea have tehrom'm
V Cbuilding construction.and hneby wthoriu tepewoutswe (Bis city to enarupon to
above-mentioned property for inspection p opoees.
f+ E•I (We)°gree to save,indemnify and kxp hamllesr to City of Cupertino again,,
U Bahilidea,judgments,cosund espmee.which may in my way acctueegalmt and City
W in consequence Of the granting of this permit. -
F` h APPLICANT UNDERSTANOti AND WILLCOMPI,YWI'i'n AILNON-POINT
V QO SOURCE REGULATIONS
$ignemm
HAZARDOUS
ofApphcaDna
-HAZARDOUS MATfiR1AL5 DISCLOSURE
will ds,°pplicam orfuart Wilding Occupant store orhandle haserdous minimal Re-roofs
u defined by the Cupertino Munidl el Code.Chapter 9.12,sad he Health and Safety h
Cade,Saction 25532(0] Type of Roof
0W ❑No . .
-
Will the applicwtar m
future building Occulting e equipment or devices which All roofs shall be inspected prior to any roofing material being
emit Imardou°ai`°°neameats a•&firm by the Bay Ama An Quality Mmaeamem 'installedAf a roof is installed without first obtaining an inspection
Distinct?
E]We C]No I agree to remove all new materials for inspection. Applicant
I have read use hazardous matuidv tequhamema mdar understands and will comply with all'non point source regulations. i
Chgand of Nc Cali- P Y
Tania Heart A t coma Code.Seen=g ,seen is my ad 255X I and the if the '
Wilding thou era curtwBy havicetenenL Noir is my rcsponxiality to naify the occupem
Of Nercqutr lswhichmusthm pnormiauanceora Cenificele Ofl up y, -
Ownermauthonaedagent ,Dam Signature of Applicant ,t, Date
All roof coverings to be Class"B"or better
OFFICE