00020138 (2) CITY OF CUPERTINOPERMITNO. i
BUDDING DIVISION PERMIT /CONTRACTORaINFORMATION: �OQa r 3
BUILDING ADDRESS: Src.ucn
Sln1('talgktk.-MIax^MPd AAS SANI'rARYNO. APPLICATION SUBMITTAL DAT
X1+13 dh�lFor pr I'�(ioxs {L32. Z Leu (16
OWNER'S NAME:
1\J� Pte- SpnZ'o54 , to °1S1SS�(ok)1 NIC
coNTRol.a
Aon_: SV ❑
ARCHITECT/ENGINEER I3ULUING PERMIT INFO
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F 5 i LICENSED CONTRACTOR'S DECLARATION
0
0= 1 hereby amw that 1 w msi
licensed under psiona of Clothier 9(cmme
oncing Job Description
wet section TdoJ)pfDiviaPonlorte Business road Pmro,ions Code.and mrlicense i. Cat re—,
qyE, in full fou and<R y
5 U Licenxe Clean Y1 Dr. —i 5 o-1 .- V vaa•Aa�J `i.w L rM4-
-�--1���— 4w�. ptew tAnS—Lo.mr4ri
3 LL''F^ Uen •" •air •z MCNI'IFLTS DECLARATION
Fto9r1—APPs-
�a 0 1 undersand my qw eN11 W used u wblic reads
.. °� Llcenaed Proreasiural
a y OWNER-BUILDER DECLARATION
t Z< 1 hereby amw than 1 our exempt from use Contramofa License law for the
f F n following mason.(Section 703 I.S.Business and Rofeuiona Code:Any city a county
z which require.a forest to caabuw,eller,ImProve.dread ah,Or repair any nwcwe Sq. Ft. Floor Area Valuation
Poor ro its issuenca,also roccui e.the applicant for,ah p.wit to file o algncd.uamenr
she be is licensed pmuanl to Ne Firestone,Of to C.O.toel License law(Chapter 9
('coon mg wit section70W)ofDivision 3ofthe Burnham;awproranionv—Y" APN Number Occupancy Type
Wt he is e.ernpr therefrom and the basis fe,the alleged eumphon.Any weation m 3 a� u I (D
Satipn 7031.3 by any.1llcant for a fewppli
ll'objects the acant to a civil penury of
p1 mor Nen five hundred dollars($300).
I,Down'prtepropeny.oamremplorecawitw.garateo-rolerompenutiw. Required Inspections
will dote wank,eMde he Co..,.',
.is,.Imcndnda Un,
al e(sec.)Ba,Buaitof
and ity h.b Code:The C o there i License law dors nes apply m lf Owner or
property who builds or impmvea tenon,And who daa such worke deed Or
Or trough rC 111j11CpC— M4G\I� Pl.V M�MLt
his own however.the Provided Net puce improvcunu art net intended Or oRemd for
Wc.IL however. Wil dingor..sur of rncmissold whinore your irorowfor the
owns'-Wildct oi11 have Ue burden of provini that he did not W iW m impove for wr-
pose ouueM. Y
I, r of use Prapeny,em eadmively connoting with licensed cone¢ton to
conswd the Project(Sec.TIPA.Busies'a red Profcuion'Code:)The COnoamr'p Li-
wave Law docs.,apply u an owani or Property whe W ilds Or improves thereon.and
rno conttvct.
1---ch pmluv wIN—ornic'.od O Been"wnuant to the Cenlraeter"
e
License Law /
00^
1 rtexempt unser Sec. .B&P C for this moon v
OWMr De¢
e
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one Of to following dcderetiws:
❑1 Mve end win maimm�aRmnate of Conpenuo nlf-inaum fes wartrr''Compen-
sation.es provided(a er Section 3]00 0(te labor Code.Ins to perforntace of Ne
woe which this perosr,is issted.
❑1 how and will mammon n Kd s ..cn.flha w Brearerkforwhiu.h nenhis pied by Section
,y urn Labor 1wunucarnmeof to work for which his permit is issued.
My WoheVa Compensation Insvrame comer and Policy number,an:
Cartier: Polio NO.:
CERTIFlC ONOF SATIONI NFROM W00.KFJt5'
COMPENSATION INSUNANCE
(Thin satinn Dad nm W mmpletM if tc permit ie forone hundred ddlan 4I00)
or less.)
L unify that in the pezfomance of the owls for which this pewit is iuued,I shall
MI employ any present in any ma r a n m bee subjat tO t.Worker'Compen-
inion Law'of C romia.Dau n� "i b_.a
Apgicant
NONCE AP CANTS.If,after maYbg this Ceni',ge of Esernpdon,you ahold
become subject a Wo ton's Comp n'sou.n Provisions of use Labor Cade,you must
foMwilh romply with such provisions Or this pewit'lull W domed mooed.
CONSTRUC ION LENDING AGENCY
Q 0 I ben by amw to ter isacpmtmetiw len ding agency to to perfonrunce of
Z 2 to west for which Nia pewit is issad(Sec.7097,Civ.CJ
tense/'Nem. ' r-I
a ;ov IendeYa Address
L17a I certify tat 1 have rood tin oW icalim and mate that to above iulboun ion is
L z Iona..I ago to comply with all city utl county wdtances Wn ink m sulaws o,b
7 Z bidda,goon.wction.andhereby.uthoriarpnsenmivrofihiscityucnsruponthe FEB 16
f..) abolons"hinhol Progeny fer In,orbon Put FEB
6k F« (We)agree to neve,indemnify and keep hawless the City of Consent"against
O V liabilities,judi coos and capenxs wbich may in any way acme against said City
�... W in consequence of rhe&anon,of tis pewit.
d APPLICANI'UNDER.SI'ANDS AND WILL COMPLY WITH ALL NDN-POINT By
�
z SOURCE REGULATIONS
Sgruan u(ApplieanVCwpala Dote
HAZARDOUS MATERIALS DISCLOSURE
Will teeppbrantor future building acapentamm or handle hasallous mannel Re-roofs
as defined by the CupaninO Municipal Code Chafer 9.12,and to Health and Safety Type of Roof
Care Section 15532(.)? yP
0Yes ❑No
Win the applicant or future Wilding Occupant can equipment or devicm whim All roofs shall be inspected pro roofing, material being-
erNlherardeusairconuuninanaasdefinedbytheBayAreaAirQualityManagcmem installed. If a roof is m without first obtaining an inspection
40Diauilt]
❑Yes ON. d
I agree to remov new materials for inspection. Applicant
l have rare the heamnJooa m' s'h reuinnena wWer Chapter 6.95 of the Cdi- un erstand will comply with all non point source regulations.
toms.Health It Safely Cade.Sections 25505.25533 and 25534.I undvsund tet if the ) —O0
Wilding doo.rolew fly have a roam.the it is my,i'Asiknioy mnmif,the OC[owl /�V
of dae no turenenu which must be net pria in issuance of a Cmif me of Occupancy.
Signa e of Ap locant Date
Owner or eutoozed agent Date
All roof coverings to be Class"B"or better
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