00040088 (2) CITY OF CUPERTINO P wMIT No.
BUILDING DIVISION PERMIT CO TRA p OO A OO /y, OO Q Q'
BUILDt� C—J �. /_ lJ� U C1
3 � �1 /ON �S �{�e/a �� SANITARY NO PPLICATION SUBMITTAL DATE
O NAME e - m IZ// / `�'%yrop
N/C CONTROLp
AMA CNC: -
ARCHITECf/ENGINEER
�OO '
F a? LICENSED CONTRACTOR'S DECLARATION
Z
O H_ I helsby aRrm Net I w 1¢sawd tosser provisions of Clupur 9(wmmets feel Job Description - -
F ,_asci withSection7000)of Division3ofth Bsisas ua Rofbaios Cade.aM myli«mue
<y f in full farce ecu. - ' tr
Lowy IJ ses.0 L
3 H
Dal CAntrwmr y-
h.g o O� anal b CrS DELLA 710th `rc(.1� /V CiC��/ Scq�ja//(/Q�'qs+ I uMessler4 my plw slWl h usW as public rtc«ds
ISrrnud Rofeni.sl
•� OWNER-tom
.DER DECLARATION
Z< r
hereby
affrm that I am evempt from the Con.wmra My law for the -
�C falowin8 Hawn.(Sectiw 7031.5.9uanns aM Profcasios Cade:MY city«cwnry
W_m which requires a permit m caa rant-ober,improve,keeliN,or repair any erucwe
n3_ porwIts isuuves.A.requires th appb,.t f.,,.h pontut he Elea xis«e aumonent .Sq. F[. FloorArea nation
Val
that he is licensW prsutnt to Ole provisions of the Contractors Ueenw Lew(Cheptar9
(comme«itt"th Seed.7").f Divillw Sof the Burros east profmiana Costa)or APN Number - Occas ant T e
Nal he is eseW therefrom aM rhe basis for the al<gW snonst an.My o.ba a l of P Y YP
Seed.7031.3 by any applicant fora permit wbjecta the applicant m e civil penalty of Z 75 0..�`�^ O/�/ S
«more has Eve huMted cl.11an(SSW).
I,ere owner err Ne propny,mmy mnplayw with wagnastbe'v wlc wtnpeseuon, Required Inspections
will do the work,aM due swctun u are,intealml or ReI for aah:(See.70th.Buvircu
wd Ptofesaios Cade:The Conuslor'i License saw does nor,apply to as awrur of
property who builds or improv.therwn,ata wh club such work himself«though
his own employers,pros' menu ase M imendW«oRe,W for
sae.IL howe ddingmimprommensha 'norcyseadconeplaiw,rh
owner swill have Nc Wmme of proving that he did iM m impom for put 77
ewe.). ..
I.m ncr of Ne propny,em exdmimlY contrecting with li sed cturl .
wwct Ne projen Igo.7016,Businbn.M Profeuios Cade:) Co thor urn U-
"rwauwdoesnota W.ownbofpmpmywWWildn«im Vb therew,aM
is f.rxu rolccu wiNacantsalm(a)licenwcl punuan Ne Covincrm's
ace ll a law.
❑lames funder a. BPC for this mason •" �\
Deis a
ARATION
y alfirm a der pastry of parboryone o e o M.8 daclantiw:
I live an 'a a Certificwe ocoral to wlf-insum for Workers Compton-. -
cation,at pmvldW fm by section 3700 of the Labor Cade,for the psfamtaoee of the
work for which toter permit is issued. _
❑1 hem aM will maintain Workers C.mpe wslion Irnma«e,as required by SMion
37W.f the labor cram,forth.perfomwc.lobe work for whish Nin permit is i..W.
"Y' w note b and Polley t�mk�
urie�V_7dY' Pabcy N.,k(�C/=L.'$ �S299
CERTIFICATE OP EKEMPUiNN PROM WORKERS'
COMpENSAT1ONiNSURANCE /J`?$
r
(This smion neW ma Wc«nplclW i(thpcmur infor.«h do an l-5100) I ,
or Inn.)
I employ
an,We.
in the slay,reso na of the wast f«which this permit is iuoe41 shell
not employ any Canon in any,manrcr w.to..Come xubjbt to the Worker,C.mpcn-
aslpliof Caifamie.Dau
Applie.,cant '
NOTICE TO APPLICANT:IL afar making Nis CeiORbu to ulsor m, ,y o most
become 6 comp to the W eh ra Compnnuw provisions of le labor CWct. most ,
farthwiNcomply with such provisiwmNis pennitaWlWdecnrd scvokW.
CONSTRUCTION LENDING AGENCY
0 Q IhetebydRnmthwlheroisacannr..do.lrnding eg.y for the prfomtance of
Z, the work for which this permit is itownd(Sea 3097,Civ.C.)
^E„^ Ulmer,N.
a >
Ureter
n Addie .
[y Q y tiw 1 hive ad Nu application an Nat the above lot.".is
At gree m wmply with al city arta counry!dine 6 aM alwt laws rtlwing ro
Z Coa ding co s=rbn•aM hereby aulWriae rspmsentwivno 's city to coast upas the '
C.) above-mensiwW papertY f«inspection Purposes. -
Gz (We)agree m cava indemnify sell keep hasnleas the Ci of Cupertino egast
liab" acbuande hex whichmayinanYwlt cse again,,said City
�., mConmilosrce Nis p.mil.
APPLICA ND STA SA COMPI.YWITH LLNON-POINT
SOURCE GUTA' ON l
SI titan ovtncl!
Kant or futum Wilding oecupwrc weasels, or handle havamos meuda Re-ro
m defined by the Cupertino Munictell Coda Chapter 9.1;aW the Heath mel Safety'
CM.,Seotr..25s3g(a7 e of Roof
❑Yes
Wiillthe.,Nwantmrmurt Wilding«c r uta Nuipmeat.,&e ioalwhic,h All roofs shall be inspected p r toanroofing material being
not hft dous air coleamisnu as deMcd by the Arcs Air Quality Management installed If a roof is installed ithout first obtaining an inspection
I6viC1[]Yet a e all new mate ials for inspection. Applicant
Ih.v the d.0 snatenasregarcmenue . Cb.pur6.95.fiheUi- er a s d will comply ith all non point source regulations.
fmslie H1 t e,SeNw 25505,25533 end 5M.l ulderswld tot itdu
_ n cu OY Have a termor.Nwitismyres nsibilitym,wtiryth occupnI Q�(1
of uue 'ch 6r be mw prior ro ueu .fact . .0 Cao.
Signal Ap I Date
Owrcr or authmi .gens am ,
All roof coverings to be ass"B"or better
OFFICE