00020091 (2) CITY OF CUPERTINOPERMITNOq.
N
BUILDING DIVISION PERMIT CONTRACTOR3FORMATION: OZ O I
BUILDING ADDRESS:
1 O L I �� ��� SANII'AkY NO. A•�y'�LI^ATIONSUBMITTAL DATE
7 '�,�a"��ff //y 4 (�
OWNEWS NAME: _ n ( lad/ \ `�rP� / I �ZDOIaa
er✓ NIC CONTROLS
D
ARCHITECT GhYEE IULDING PERMrf INFO ' .L-,e;
UQ U t)
yea
Lal
LICENSED CONURACTORS DECLARATION
of CON
O Z E e hereby affirm mat T am fcan Bu under and
Poonms of shaper 9(commencing Job Description
�tw cons Sation]0oa)ofDivision3ofJe Business and Pmfclaiom Cade.aotl mYlicense u '/�
y ,'�j in NII force sod cRat. f(�� f/,a,f e ve V
e0 U Dae. Class Lia.. VV--tt
uy� Date Conuacmr
tO g
c ARCHITECTS DECLARATION
5 I understand my plans shall be uud as public records
y 6 e O
Iicesecd uiov
Profel
oS= OWNER-BUDDER DECLARATION
I-Z< 1 hereby aRrm that 1 sm exempt from the ContncmYs Utensils Law for the
` D following...(Section W31 S.Bu,iusa ad Pmfessiu,Code:Any city Or county
s m which repine,a permit to conswa,wet.improve,demolish,or repair any structure Sq. Ft F or Are• Valuation o
prior to its i,vusna,also regales me applicant for such 1117110w file a signal an ement n_
that he is licewal prrsumt t0 me provisions or me Con ramma Liam a law(Cbaper 9 (7 VI 2�� 0 0 I
(mrmossingwih Sectign]Doo)cxfoiaision3af me Baalun coal Poressiaw code)" APN Number - Occu a c
wt he is eaemp therefrom add me baais fin,the alleged eso paust Any„aaJae or (' P Y Type
Section 7031.5 by coy applicant fora permit subject,he appnt licato a civil pane of 3q2
2
pa more man five hundred dollen WWI.
1,as owner of the prapeny.nrmyemployees with wages a,their sale compenaation. - Required Inspections
rum domassime enema tvunmiusmot itucrdeder sw doesorota(pi'm an Bwiuss
aha 1',Who
Cade:M Comtanor's[.kenos law dos not apply to if owner of
his o ny cow buil",or impovu thsuch std who sus sucss n rinte hioro Jed for
his own employ. a WiL dal that such imntiz"nu are nun intendedyofca offer.for
mareaL howeves,JU Wilding burden
of movant it cold wild nano yw ofmproverion,C, j
-wooer win here me wrden or proving that bo am not woe m improve rot ver-
W glee. ��
r of me property,am exclusively cormumng with licemed convenors to
strvct me project(Sm.IDN,Rusiuss sod professions Codc:)Th<Contractor's Li-
cewe law dew such
apply to an with
a of popcny cow wilds m impo the Como,ors O
cow contracts f«such projau with a canvactort0liccnad pusum w the Convector,
5L law. -
❑lamaxcmpt Sa; .B&P C for Cis won
Owner Date vlq ho
WORKER'S COMPPSATIOIN DECI.AMTION
1-7
1 heRM1Y eRrm undo pmaltY perryry au of the following"«[onrush:
]1five and will maintainetion 370 of fomentm [aim,for far Woom of
mirk,as provided for by Section 3]00 of Jte Laver Cale,for the pcAomunu of the
work fru aid Cis permit is issued.
❑1have adwill mutation e,per C.offltiurk far ce,as whih1n.per by Section
My Warne laver Code.for the pcHamance of Js wort far which thio permit is i,wd.
Ca e,: Cempcwtion Insurance cerrim nal Polity number are:
Carrier: Policy
CERTIFlC OF ION MOM WORKERS'
COO MPENSATIONSATIONINSURANCE
(Thi,action nail not he cnmpletd irme pertnit is forou hgodrd ddlers(S1o0)
cr less.)
T certify Cat in the performaue of the w«t Nr which this permit is iswd.I small
not employ any person in any manor eco u to become subject to the Workers'Comyen-
setion laws of California.Dae
Appicwt
NOTICE TO APPLICANT.If,after making his Certificate of Exemption,you should
become robiat m me Wankel,Compensation pmvioiona of me Labor Code.you Cwt
farCw"h comply with such provialgns or this permit shall he clamed Rvokd.
CONSTRUCTION LENDING AGENCY
O Q I hereby affirm Iliad them i,a cowN
won[coding agency for the performance of
y the work for which this pcnmit is issued(Sec.70)7,Civ.CJ
a Lendelm
,Nae
Lo=x Addeo,
fs: T comfy Chet 1 have read!mi,application and suit that the above infomuaon Is
A. 0sect.I agree m comply with all city and iausd county ordnalore laws relating to
Z buimingconxorcaon.and hereby auJwriew reproenhtiver oflNsciry to morapon the
U O aWve.menamd property tar inspection purposes.
W P (We)agrm to save,indemnify and kap harmless the City of Cupertino against
O C.) liabilities,judgments,court and expenses which may in any way accme against laid City
>. W in commanumem Of the Starring of Cis permit.
E" 6r AYPLICAN UNDERSTANDS AND WILLCOMPLYJJJ///LTH ALL NON POINr
J,JU
Sty URCI' �IONS. r Z�/�/� .
.. /' /nka . a� �/f a--/fes//
Signat�APPlicanu Z'Q' T able v • �' I 1
HAZARDOUS TERIATS DISCI 0SUR e
Will thearplicadn orfutuR dingucupmismR or ladle haradoux material Re-roofs
w defied by the Cupertino Municipal Code.Chapter 9.12,ad he Hesi ad Safety Type of Roof
Code,Section M532(s)] YP
Ye, ❑No
Will the epploanr Or future Wilding ucupenr use equipment or devices which All roofs shall be inspected prior to any roofing material being
emithaten°"wrdOu,air conuminanu as defined by the Bay Arca Ab Quality Management installed. If a roof is installed without first obtaining an inspection❑Yw No
I a ree to remove all new materials for inspection. Applicant
Im ❑
I have Rad arc hares low materials equiremane under Clupter 695 ofthe Cali un erstands and will comply with all non point source regulations.
forma Health&Safety Cod0.Sections 25505,25333 and 25530,1 understand lid if the
building alas nun curremly have a tenant.Ca'n is my responsibility t0 notify he ucupant
of the R9wRmene which mu.t be rat pie ro isauauc of a Certificate Or Occupancy. .
Signature of Applicant Date
Ower or indeed zed agent Dae
All roof coverings to be Class"B"or better
OFFICE