00030083 (2) fBUILDING
ITY OF CUPERTINO ` N fes' ` PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTR`INFORMA,TION: U b 3 Q O 3
ADDRESS' /
�OGA�/ /I� l ^, ANI'1'ARVNO APPLICATION SUBMITTAL DATE
N[R'SyyAMF. 1- .��•/Z�/O41,4 f. 7—C-4? V �/
CR'S G. CONTROL#
Am PHUNr
G S 5 13ULDING PERMITINFO $%
ARCHITEC TNGINEER
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'-H Z LICENSED CONTRACTOR'S DECLARATION ,IpDescription
Job Dl tlOn
Z O - I hereby'Rm m,
u1 am licensed order provisions of Chapter 9(commeneing P
s0-,_[_u with Smtion]000)ofDivision3of he BusincesWProfessiam Cade.end mylicemeis
y S in full face and effect.
n w< Bemis Clain
vi 3 z Date Cmtsxmr
F.a O< ARCNTfECTS DECLARATION
�v
1 undenmil my pluu'hell be used as public record.
c. Laccnmd PmNsam.t
d OWNER-BURDER DECLARATION
Z>' F hereby eRrm that 1 am exempt from Ne Consracton's Licenx Law for ted
2 i D following newm.Ztion]031.5,Business and professions Code:Any city or county
u 3 m which requires.permit m catamuM doer,improve.demolish,re repair any lrmcmm S Ft. Floor Area Valuation
priato its isswna,smrequire,theapplicmt fonuch permit m file asigneda.tement q OU
that M is licensed emener,to me Provisions of the Conracmra License Law(Chap"9
morournmem,with Section 70DO)of Division 3 of tW Business Ford Purfirsaime Code)in APN Number Occupancy Type
that he is exempt th,sfmm and he basis for me alleged exemption.Any violation of
Section 10313 by my n,,fam fora permit objects the epplicmt to a civil penalty of V
trot more men five hundred dollen Will).
❑1.as aroma,of the pmpeny,m my employees with wag".weir role emnpema.tian. Required Inspections
will dome work,and the amuclme is not isesrdedon-Marl faaae(Sec.11N6.Business
.M Redessla.Code:The Contract's Lia,'law does FOR apply to an owner of ,
property who builda or impmves mermn,.d who does such work himself or through
his own employees,provided this such improvements—nor intended a offered for
We.If.howcrcr,me building a hin one improvement is sold wityear.(.ropleim,he
mvwu-iwjlder will have she bounce of proving Jut he did not build re initiative for pur- _
you of sae.). Il sirr t-�
I.u owner of me property.am exclusively cmgedng with licensed tors i-
construct he mj"t(S«.7M ,Buuis,aid Professions Code)Tie ContrecoMa
Li-
License U D
are law docs trot applymanowva ofproanywW Wil4 or impeov"damn,W I �
coed contracts for such proja.with ecmvacoorls)Ikensed punuantm Oe Contrxcors I
law.
�Iam aero urperGtt. .B&P fad 3 '� MAR 1 2000
Owncr�o
WORKER'S COMPENSATION DE / ZrY'/1(►,
!hvebY afinn under penalty of perjury one of he following declines.:
❑l have and will rommen a Certificate decadent to self-ituurt fm WoheYa Cmmpen
cation.in pervaded for by S"tion 3700 of me Labor Cade,fa the Perfomamen of lime Q _
wet fa which this permit is issued. M1
❑I neve ad will maintain worker,Compensation lrgmarue.u requited by Section
31W of rhs lobe Code,la the pertorm"rce of de work his which this Pent"is hunted.
My WuArrs Compensation In..canner and Policy numb,For:
Cagier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thia'ectim d m" not tecompleedifthe Permit is for one hudredd Was15100)
Fir has.)
I employ
my matin me pg(.., of he won for which his 11W W is iaeved,l ierI
rot employ any Petsrn in any manner so,ro Fccone subjar to me waken'Coram
satim laws of Ca immia.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,You should
harms subject in the Workda Compensation Provisions of he labor Code,you run
foMwim comply with such provisions a this'remit abell W domed nevoked.
CONSTRUCTION LENDING AGENCY
I h,eby.ffirm thm mere i........firm l"Wing agmay,forth,Performance of
Z the work for which his permit is issued(Sm.3097.Civ.C.)
Lenders Nemo
a 7 Landers Address
W I certify thin I have rad his application mission dont he above Inf.u.s.Is
0. conal.l agree m comply with 9161,and county odumm"s and sate laws rtlnmg Ir
7 Z building cans.udov,and hereby auhodu repmembeives ofthis city to enter upon the
V ,Wvc.mamioned puoany fa inspection purposes.
tar E✓ (We)agree in save,indemnify and lump hgml"s me City of Cupertino agumt
Q O lunines,joeguens,me.and.Peres which may in any way accmeeg.just said City
W in consequence of he grentimg of this Permit.
ti 4 APPI,ICAN'TUNDERSrANDSANOW ' MPI.YWTTHAI.1. ON-1 )INTaA
V z SOURCE.I'A'dicam/c �� 7 ,37v /3
7v /,-�a
Sib'^im(dnnafj�A/pp/✓li'1aHAZARD--ectue Date �,}� / /✓-S
HAZARD---
Will
LSDStoreMURE
will me epplicmtor Ntae Wilding acupmtsmreahadk hnrardoua materia
nee defined by he C.,muma Municipal Cock.ChaOter 9.12,ad the ficah and Safety Type of Roof
Code,Section 2553x10)+ YP
Cl Y„ O
Will he eppli,.,or future building cmupant use equipment or devices which All roofs shall be inspected prior to any roofing material being.
smut hafa'doua ab commorwm.u defined by the Bay Arca Air Quality Managcmcm installed. If a roof is installed without t-irst obtaining an inspection
District? J/ I agree to remove all new materials for inspection. Applicant
CYes dN'o g
I hive read the haunt.,mateiaarryuirtmcn.oder Chaise'695 Of the Cul- Understands and will comply with all non Vpom source regulations.
fume Health&Safety Cade,Sections 25505.25533 end 25530.1 understand that if the
building drama currently have a temam,that it is my rtsponsibil' o.mn ythe acupmt
Ofh 'whin yJy.xwpQOr to issuanao C fie eupanry.
Signature of Applicant D to
won or aumorizedagcm Do.
All roof coverings to be Class"B"or better
OFFICE