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00040175 (2) CITY OF CUPERTINO ` " " " e' PERMIT NO. emcolNc mvlskoN PERMIT CONTRACTOR IN"!Vt I�IOO N�'' ©D �/�/�� . t T BUILDINGADDRESS n /t /` �//q (� /D 213 Y[3 /JI r Q/�t e� C. ' �ec V 1 ` F- /4Jc- SANITARY NO, APPLICATION SUBMITTAL DATE OWNEg'SN LEI Vr'jA 'lf� IJI�� �a/rl �'T'l 0 2� � A Un;-- k g NIC CONTROLX 40 ION�;��,NN118 2.S.S-S.2/O jtij////�����- V/ � � ARCH rECf/ENGINEER 9(T-n v- O BULDING PERMITINFO, o rs FZF T`-� �f xroU U Qc 0 O i ereby LICENSED CONTRACTOR'S DECLARATION 0 0= 1 haffirm Nat 1 and licensed under pmvisions'f Ghapar 9(commercing Job Description s-=Cro NSectron]000)ofD'vision3ofNe Buaia"esand R.fevians Code,aed mylicenm is n full fora Cleanse Cles c �� Lic.N S7 in 3 - w3a�, DateCCan RHrEC SDECLr ARA ON 1 zu�Q S I undenud mY Plans ahotl be used u Public rcc«da K n C D Ulcerated '"NeulmW ud^_ OWNER-BUR.DER DECLARATION h Z a I hereby affirm that 1 am exempt from the Conaacsms License Law for fee 7=n following reason.(Section 703 L5,Business and Rafmiom Code:Any city m county !_ which"..a pnmit to construct,user,improve,demoliah,m rtpur any rads. S Ft. Floor Area tlJ / Valuation 3 m prior to is m...ce,um requires theapplicant foreoch permit 1.file.dicrudmmcn s< s q' Jb ,v/O 1 &z:> that he is licensed porous.,to the provisions of Ne Contractors License Law(Chapter 9 (mmmen.i.gwith Serum.7W)ofDivision3offtBusinnaaddprores.i.Cobs)m APN Numb Occupancy T Ws he attempt Naefram and Be Weis far the ulegcd exemption Any violadm of /, P Y YPe ca Section 7031.5 by any applint For.permit subjects the apphersnno a civil penalty of 3/ s'/� -D u one no mme Nan rve bodrd dollars(55001. Lasewme of N<propeny.amy employ«s with wags uNeu wlc conrpensuiw. Required Inspections will do Ncwork,and Ne.tmcturc is nos inrcded moRerd fo W<(Sec.]Ma.Business and Rofesuoh Code:The over th son's.sol w law does Trot apply m if awrcr of propmy who builds e i o Con Merton,and who aw dsuch work himself m arse,througha his own employees,provided that such impovanents am no intended m offered for role.r-however llhave dingorimpovcment asold within oneild ofmprove for dor -builder will have Ne burden of proving that W did no build or improve for plus- / pose of sale.). Q � ' ❑st o owner of Ore PropartY•un ides,vely cony«ting with:)The Ccontract's "Nue Lits d proe,soject rally .art Bon i m' sed Rafess,Wi Cade:)The Cmtram'ra Li- JVD whocotwctsfr such jmmown«ochow,ndswca Wildsor imWo se Nercon,ad �^ whonse Law.f«such p'jecu with s canb«tMs)licewd purswm to Ne Canuanors V 0 1 se law. 1 am exempt undo Sec. .B A P C for Nis vwn ' Owner Date WORKER'S COMPENSATION DECLARATION - 1 hereby affirm under penury of perjury orc of the following declamations: I have and will mainum.CesiOcate of Consent m solf-insu¢fm Workers Compan- sation,as provided for by Section 37W of the Labor Cdc.for the performance of rhe or fo which this permit is issued. love and will maintain Worker's C'mpansesion Nando x,as retained by Sectim 3 of NcLLebor Cole..iforrthe perform—of ds work fre which Nis permit is issued, CurierV�l%< ton <artinPo Polo bcr 271 QI 7 CERTIFICATE OF EXEMPTION FROM WORRIERS' COMPENSATION INSURANCE (This section need no bar compleud if dre permit is for.«hundred doles($100) m leas.) I caddy Nat in the performameof the work for which this permit is issued,I shot] not employ any parson in toy mummer m as to become subject to N<Worom'Compan- - ,aion Laws of California.Data Applicant NOTICE TO APPLICANT:If,after making this C<nificare of Es«tption,you should ,come subject to she Worker.Compannrion provisions of the labor Cede.You muss forthwith comply with such provisions or this permit"I be claimed rtvWd. CONSTRUC ION LENDING AGENCY O Q I hereaffirm by arm NU ocmis a construction lending agency for m e perfoa«c of Z Ne work for which Ni.permit i.i.sued(Sec.3097.Civ.C.) a4 lenders Name } Leaders Address CT7 0 1 certify Nat I have red this application and Rote Nes the above information is �. correct.I agree to comply with all city ad emmy ordinances and Nine laws relating m Z building construction.end homey suhoria rtprt«nWiv«of this city to mar upon the U O above-mentioned property for impecd.purposes. fro F (We)agree m ave,indemnify end keep,hamdess she City of Cupertino against O f..) lisbilitiea.jdgoena.<maaad<xpamca which may in an way scene age=said City } W in coruequcarc of Ne 8ranti of Nis pemtit. P. APPLICANT 'IIER.S-I' tiANU WILL.CO. L ')loll ACI.N(]N1'OhNT In S UIR riGr .ATW Signet..fApihAadJComr0. Data / r�� '✓ HAZARDOUSMAT A DISCLOSURE Will Ne applicant or future buildin enntore or handle housed.material Re-roofs a+dcfi«d by she Cupertino Municipal C ser 9.12,ad are Head snd Safety Cde.Sccuuru532(.n Type of Roof [I Y. ?0. W'tB N<applicant ar to bailding'«spans n,e e9'ip«m or dm<n which All roofs shall be inspected prior to any roofing material being 1 Word.uaairconsamirunua,definedbyOaBayArcaAirpualiryManagcm<nt installed. If a roof is Installed without first obtaining an inspection 16n1C19 I a ree to remove all new materials for inspection. Applicant 40 ❑Yes �No I have dual the Waal maarial.rcN'ircmenaa r later 6.95 of the Cali. un erstands and will comply with all non point source regulations. ('rots NeaIN ffi Safe y Code 'oro 25505,25533 .I understand Nu if the Wilding does" rrtntlyh at Nat it is rte "IirymnaifY SW«cupmr u which qn pane or C e M <upuKy. LWT a r<�' -� Signature of Applicant Date oraadwriad agent Data UZ All roof coverings to be Class"B"or better OFFICE