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00030162 (2) CITY OF CUPERTINO PERMIT No. BUILDING DIVISION PERMIT CONTRACTOR INFORMATIION:�// ,r�oo tlU1LDING ADDRESS: - �a _ � �J HL•3 �� �� , �L/.{.�/• Q � l ®�,j�// G SANITARYNO A LIC?TIONSUBMITTALDATI OW 'S NAME' f7''N� // 0/ V s � �• / N/C 'bC[O-NTROL# _ I3GN-ae w2 S3 - 0 3 A/ Q¢ °IS✓/Z ARCHITECT/ENGINF.LR BULUING PERMIT INFO 0 0 m <j r `a^ LICENSED CONTRACTOR'S DECLARATION OZ Ibeubyaffirmtalw lice dunderpm sin ofchv 9(<nmm ng Job Description' r_w with Salon 1000)ofDivition3or Ne Buainns srm R�/ofw•giom Gode,Wm liansia �,//J �,//� / ^-' X77 =sen Uful�lforc-aMeBecat. 162 Li<.,a 42213 cFoWz k: /ne-w I ��^y �� LlAlL 3OQ Delo s ARCHITECT'S DECLARATION N' /y `( KL��AC��G/eN/ ®/e CI' 1T/e41 w -I 1 undenwM my plans shall be usd as public records _ oon2oc^ FDG1-UdrJ�7pn1 Q�C.9N QG�/ ��� .t41/1f •d z Li<emd Pmfeaiovl u'9-y opt NERheU mpt ft=me Cone ION ON F z< 1 beaDY affirm that 1 an caemq from Ne ContaecroYs License law,for Ne RIC' F 0 following moron.(Stttion]031.5.Business aM Pmkniaw Cade:Any city or euro, i 3 m which rerfu;rer a permit N construct,amen.improve, lan slim.or saw any awcauc ®©�lu:lG�'on prior to its ranmance.also reclaims Ne applicant for such permit to file.tigrad comment Sq. Ft. Floor Area n Van Y Net he is licensed purrumuo Na provisions of Ne Contracom's Licen.ne Lew(Chapter 9 Icon ncingwiNSecGon7000)ofDivirion3ofNeBusinea.adProfosionrCada)or APN Nurnber 3G 6— / Q g e3id,�t,e✓Occu ane Type Nat his cumNcrtlmm sant tie,burs for alleged cemron.Any ereo Suttn103LSbyanyapplicant faapemdosubjects gppluato.civlpedy, of rot mac dun Eve hurdrd dollen 15300). wi Lahe"rof Ne pro pcnyomycmntende orowagnnNe(Scu.cempemaian. Required Inspections , will dofework.ands: oCortistot intended Law dfoorapply to an Business and prefer..who Cade:the Contractor License law dia,such not apply m if owrro of his o nY who builds or impovee Name,ed who d.er such work intended himself orthroughfor his n employee pmndd the such imparcmcmv thin nor iyear of or offered for Wer-however,ll building iimp f pm,,m Is sold within oroy...ofcampledon,da po e, W e.).will harc the Widen of proving Net he did no Wild o improve for per- 1,as weer of the property,,I timars and conmdng with En.sd common a Construct La the es out appl(Socey to x4,owner of W Professions ds or unproven Cn.nanon,ti- cnuc law deco mn apply to an owner m proPany who Wilds m impovn Norton,W wW connects for such pmjeca with aconuacmr(s)lic.nrd punwnt a da Contractors Lc toss law. (]I an exempt under Su. .B�&'$P C for this seams ��� aro wn — Dae O(J GG W tKER'S COMPENSATION DECLARATION nm under penalty of perjury urn of de,foll.i.g decluatiom: .0\ ❑I have.d will ornmo in.CanlRca¢of Cormw(t.sel6marm,frrWorkeri Compete- `)40 satim.a povidad for by Sudo.3100 of Na Labor Code.fo.M pd..of Ne `J work for which it permit is issued. I have and will maimin Wnrbeen Compensation Iran.,as requird by Saeion 3100of thc labor Code,for the pedommoce oldie work far which Nis permit it i-Imal MY Wor over Compensation lemmata came and Polity mumber vin: Carrie: Policy No.: CERTIFICATE OF EKEMPTION FROM WORKERS' COMPENSATION INSURANCE (This scrim bod not W completed dNe panni,is lororchundrddollan($100) ' m Ices.) 1 onpersony wt in he performance o asa work for which this pemN is abound,I shall not employ y any peon in any manner so as become object a the Workers'Compo- � xarinn Ldws o OTI TO P IC F.If,atre rmking this Comfit..of Eaempdan.You should ream irlass Compensation pmviva..of the labor Coda,yw mart forthwith comply with such provisions or this permit shall In,doomed rtvokd. CONSTRUCTION LENDING AGENCY O 0 Ihereby affirm then Nen is a construction lending agency for the performanm of the work for which this .It is issued(S.,3091,Civ.C.) I Lender's Name C, > Lender's Addre.x W E I cenily that 1 have reed this application and two khat da slave infmmedan i. 6 .vett.I agree to comply with all city ad coumy odhunces and an a law.awing m Z buildingco. syszvon.vW hencbYauNoriu npnnonwives of this city m rotor upon the U O abovc-menrioned papeory for inspection purynsas, Rr F (We).grce to cave,indemnify and keep hamslesr the City of Cupertino against O O liahilnes,iadgmema e.uram rapemea which may in any way nccma.gamot said City ry ac.me9uenco of the Granting of this prmir. 6r 'A PPLICANT UNI)RRSI'ANTIS AND WI LI.COM PLY WITH ALL NON-POIN1' V Z SOURCE.REGULATIONS. 51/2 Ae SigEa alA cmUConuactor Oso HAZARDOUS MATERIALS DISCLOSURE Will the applilsem.,future Wilding Mc.pemaure.r handle haaalous material Re-roofs as defied by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cede,Section 25532(a)1Type of Roof ❑Yn Win thea applicant orfor=Wilding occupant use wuiprcm or devices which All roofs shall be inspected prior to any roofing material being qp .c nd(hanrd..a au contaminants as defied by the Bay Arca Am Quality Masagemcnt installed. If a roof is Installed without first obtaining an inspection °ita�" ❑yes ❑� I a ree to remove all new materials for inspection. Applicant I have red the hamduus maanals rt9oimmenta under Chapter 6.95 of the Cali- uncierstands and will comply with all non point source regulations. forma Health&Safety Cde,Sections 25505,25533 and 25530.1 understand that if Ne Wilding dean no emmmly have s tE I,that it is my responsibility an notify Ne occupant an be rht0 I,ueu.of rf<a.f Ca rcy Signature of Applicant Date nu d.genr Dan All roof coverings to be Class`B"or better OFFICE