00030080 (2) CITY OF CUPERTINO - PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION: 000-3 �O
BUILDING ADDRESS: /�
GO//y.ab1� 90
SANI'I'ARYNO. APPI.ICA'f1ON SUBMITTAL DATE
OWN'
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ARCHITECI'yI�EER� V/
BOLDING PERMIT INFO'
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F N 7 LICENSED CONTRACTOR'S DECLARATION
F=
0 O w 1 hereby affirm that 1 sin licensed under provisions of Chapter 9(cnencing Job Description
tns�s mmwish Sation?000)ofDivii n3ofine Buxinesaed ProfwiomCode,Wm^y�liunse is
'< S.'i infullfoxecud<ffes,' ��a/ .lit T.I
3 u Datemc Clear Conttennr G� GQ a{/ Ale-
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u.O g ARC TTECTS DECLA O ff
1 undemud my plans shall be used in public rccmds
res
a S z Lmmsed Profeuircal
-o, OWNER-11111 ER DECl.3RAT10N
t Z a 1 hereby affirm than 1 am exempt from Ne Cootraeors License law fix,the
F C following reason,(Smion 703I.S.Business and!Profevimu Code:ke,city w county
m which require a permit in comwet,alta,improve,demolish,ce repair any snucwe
°•5— Porno its suitors.,than requires meapplicantf...chPeramanhlcasigncdannounce, Sq. Ft. Floor Area / Valuation
that he is licensed Pursuant to the provisions of the Contr¢tds License law(Chapter 9
(c m ncingwimsecdon7")orDivisim3of eBuaimesamP fmim CWe)ro ApN Number Occupancy
wt he is exempt therefrom w the Wait for Be alleged exemption.Any violadun of 2 OO P Y Type
Section 701.5 by...applicant fix.permit subjecm,h applicant to a civil pemlry of ..J
nor mom than five horrid dollars($500).
❑l,.own=rormePrrp=rtr.mmremPloymawimw.emmd,eiraae<ompemden. Required Inspections
will dome work,and the in u alum is nor imcdcd ce offered for sale(Su.7064,Business
and Profession Code:The Contractor's License Lew does ma apply to an owner of
Property who Wilda or improv.Ncrton,and who does such work himself u through
his own employees.Provided Nu such improvemema are nil intended a offered for
sale.If,however,the Wilding or improvement is sold within one yesrof cumvletion,me
rwilder will new the burden or proving that he did net Wild or improve for per. 6/
pow of 6ala.).
❑I,.owner of ted PorP=nY•em eaclusivelY convecting wire licensed convacmrs to //
construct the Pnjut(Src.70a4,Business ad Professions Code:)The Convector's V. ^
cess law does mn apply m an owner of Property,who Wilds a improv.thereon.and
who convects for such ptojecu wish a coametor(a)licensed pursuant he me Commalm's
cose
Ownerm law.
1 aexempt under SuA. .B P C fm Nis won
Owner Dem
WORKERS COMPENSATION DECLARATION
1 hereby ill mai under penalty tePerjury one of the following declarations:
d
1have. will maintain r teinacertirrcanter,t no telcmame rmwaker.comPen.
smirk,as provided fpe by$utirn 3>00 of Be Labor Cade,fa tW perfomunm of Ne
work for which this permit is issued.
37 1 have ad will ode.for a performance
Cance of.tion work
whim bis Per by Section
my mine Labor Coda for the performantt of d work for which Nis permit is inaued.
My Workclt Crmperwtion Inurenec carries end Policy number are:
Camcc Policy No.:
CERTIFICATE OF EXEMPIION FROM WORKERS'
COMPENSATION INSURANCE
(This section need no becompletd ifde permit in foronchudmddollun($100)
or less.)
1 certify than in the Performance of the work fur which this permil is ismd,l shall
nil employ any peen in any manner m m, �ej�r.;= Couriers.our�"af'.�%i�°. G✓air a ,e
PP
NOTICE PPLICANT:IL atter making This exon,o the
Bsampdm,you should
haome aubjwuo edit Worh pro Comas or this Provisions of the tabor Code,You must
frnM1wish comply wish such provisions or this pcmnitshall Wdared revoked.
z CONSTRUCTION LENDING AGENCY
C0 I herun hereby affirm dthere is.continued.lau
edinggey for she Pr,f..f 1
?. the workfor which this permit is issued see.MR.Civ.C.) �s
Candies Name
Le + g�o aLyoOo
LX 7 ndelsAddrttn MAR 1
W I certify that 1 have mad this application and state that me abuse infomutim is
Il z crena.)agree m comply with all city ad county oNimnecs and xutc laws nleing tV
z
Wilding construction,and hereby aumunce represenutives of Bis city to enter upon the
V .buvementirned property for impecdrn purpose,
is. f, (We)agree to save,idemnifr and kap harmless the City of Cupertino agaimt By
Q U Iubilides,judgments,c.m ed mpemer which may in any way shom isfu imt said City
} W inconsequence of Be Booming of mis permit.
APPLICANTUNDER.SI'ANDS ND V41LLCOMPIN WITH Ali,N(IN.PHNT
U
z4SO 1 :G
igen AWhcan r tin Dare J J` �.'v/���V C�Lt
H IpUS TER DISCLOSURE.
Win she applicant or futurt W ding pan,store or handle haa•rdrur ma xl Re-roofs
as dcfnW by Bc Cupertino Municipal Cd Chapter 9.12,cad me Hcelsh end Serety T e of Roof
Cde.Sation 25532(x)? / YP
[I yes vyff
Will tW applicant or future Wilding occupant me equipmem or devices which All roofs shall be inspected prior to any roofing material being
ha.edo.s acenumnv IS
fined mia6 ed by the Bay Are.Air Quality Mlemem installed. If a roof is Installed without first obtaining an inspection
i6ri<t? arIa gree to remove all new materials for inspection. Applicant
❑Y<s No
IWaen.d Belw,.rrdana material unpiremerttarder. Ch.Prab>5 C;,i. un�, andwill comply with all non point source regulations.
\ funis H.Ish A Safety Code.S imu;rS .75533 and 25536.1 trod the if Bc
WildinBdoea ku cunentl Fetcn B scsprnsibil' tensity the«cvpant
o eeain mussy in score Ce ihcam rf IXcupamy.
\ fir n - Signature of Ap 1 Date
r.ushrri gen Dam
\ Allorf covering&a Class`B"or better
OFFICE