00060184 (2) C4'Y OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: 1 ` PERA111'NOO O
OWNER'5 NAMIi. APPLICCk`A I'ION SUB DAI'I..
in Ni S 1'� b N i�h VQ ' - 2 — oo
IIO ry, � J SANITARY NO, COhTR01.NO.
J � tH�1-'IeJx
O O A CHITECT'/ENGINHFR: - BUILDING PERMIT INFO
��— BLOC HLFC'I' 'LU. 1 MECII
I f-1
05 3 1germyafrrcl{nmil„a.Yemalfpail i�,�fChemerv(,nnmenans ON Job Description
°wl-..w .uh Sevliun 9aXlrn nista....3nrthe Bu.inesu and Pmr ion,Cale,a ad I,,y Leen
au x I-� is in full force and e e F,
a<K < Dab,w(:lass (O I.ic.b=�t—�.4-�r�-0'c�n�—'t-n—s � I n
P a U Uac—b Commca RAILON l`k]�ky_¢k.SBAg W (vvxt1_J C.cJ.....SC•i`
y 5 a fi ANC1WH bCT'S DECLARAI ON
t_a 0 4 1 undemmnJ my plans shall he cod a.public rtrnrJx
y� 5
a a p LiccnuJ Ralcs.ional O
OWNER-BUILDER DECLARNFION
1 h..cby A.
Seo tha I um exempt from Inc Cnnmcumr'v Licen>e Luw for 1M1e
F M Q mHonvin ng reason.(Salina 9031.5,Ilasiner.cad improve.
demolish,
Calc:Any city or county
x e which rcyuim a permit m ttmzlmn,aper.imprmx.Mmolish,or repair any swctum
11 3. pr'ot 1 1 I: 1 pr uWo v t 1 1 m ter 9
(hath ,,t .. thep of the 11 t 1 License 1 (Chapter Sq, Ft. FI001'Area �� a1lIDllUll
(rat he
exempt themmu11d(nd1 DYd s for t ea alleged
exempandtion.
i n.An Code) CV/l
m that he is exempt therefmn,and bar
nasi.for the alleged cx lieana C Any violationchy
of Section 90.9 LS by au dred d ll fora permit whjecu the upplicum m u civil penalty
9f 11th more maa five M1anered dollars($500), APN Number2� Occupancy Type
m
❑1.as owner of the ppeny,or my employees with wages m their vole enm
mpentmn,
will J da,work, d the (' 011.is not intended or offered f (b ".a,
Buses -nnJl r cal nic c comm I.trenve 1 does not' apply to n
Required Inspection
ow p ty I ee on,role, d 1 rkhn- If
or through H. e ply P ' but suchimprovements (intended r
offered It 11he h Ib, p t I within Carol
completion,the h J 'll have the broken ofpng
that hId norMmilJ or /
'npn f Pat) f l ).
C1[..is of 0a,pi n) f contracting uillicensed contractor,t
I^n r thep /eci(Sec.9330 [business J Professions CN )The C naacmr s
re av l;wA vsmtal PlYt an v rfp ry.ty 'I M1uiic p tM1la the
and who contracts lot such projects with a Can(mnnns) littnsvd pursuant nm the
CamlmemI s Li'en's law,
❑I am exempt under Sec. - .B k P C fill his reaomm
Owner Dam -
WORKER'S COMI•ENSAnON DECI.ARAHON
I hereby uffrnl ander penally of perjury one al the fnlluwing declarations:
44 7 I have and will maintain n Ccnifeum of Consent to sclhinvure for Worker's
Compematioa, as provided for by Scnion 3700 of he lalwn Code, for the
perlurm;mee of the work Ibr which thio pen of le issued.
❑1 hese and will nmin At,Worker'.Cninpenswiun In uourwe.as requin•J by Seclitam
3900 of the LaMa Code,for the performance of @e work for which this permil is
cued.My Work""Congmnaemb honrance carrier and Policy man cr are:
C;nrie,119W"Y_l_Pol ey No,:05t-4-FOVIM M 8_
CIiRTIFICATION OP EXEMPTION FROM WORKERS'
COMPIiNSA'14)N INSURANCE
(This mctlon aced net be amtpleted if the Permit is Ra one hundred dollars
($tmt or Ices.)
1 cenify that Ann performance of the work for which this pennit is issued,1
xhdr 11111 employ 1111,Panna to nor manner x11 ar to become subject eu the WnrkuN
Compensaion Irws of Cal Iforma.One
Applicant
NOTICE TO APPLICANT'If,after making dais Ce-ifienou of Exemption,you should
becntne_mbjecl Co(he W ak—Cum,,enamiam provininm elite Lubse Code,you muxf
0 forthwith comply with such Provisions or this permit%hall be deemed mvoked.
Vi CONSTRUCTION LENDING AGIiNCY
I Wen,a1Bmt Ihal there is a aononengn I"don,."rue)rot Ne pcdbrmance ..
of she work for which this Penni,is iswed(Sec.30U.Civ.C)
CL Q Lcadcr's Name -
VC I cenify to cI have read anis City
Can
and orae that the aMwe inaws elati is
tat F in Decd.1 gg1CCcon to comply with all city and aCalialy
mpmordininces ane xta1e lows relating
Q tt m ab,,,ng construction, kahyamhoon pupoce. fives of this sip mcmcrurym
he nb t 1 11 1.ny y d'o p car
ti0. (W) " t indemnify keepJl I vthoC tyaf Some CnmC nu
(n 1 btl t 1 db r' f t pe :. wl y n any way ammo a"uimt xuW
(,) Z City m mnxquence of the gr nu 6 fs(ti s pc t.
APPLIC UNDHRSI'AN 5 N 5 COMYLYWITfIALLNON-POINT Issued by: � Dille CC//
SOURC F'
Sign.(— plcandQm tm or Dam Re-roofs
IIALA >US MA4'ERIAIS DISCLOSURE
Will the alt or future Wilding occupant Store or handle ha.aalaa.mateaal Type of Roof
as defined by the Culmninu Municipal Cale,Chapter 9.12 and the Health and Safety
Code.Section 255320)4
❑Yea C1 No All roofs shall be inspected prior to any roofing material being installed.
wdl the applbcCal or furore building oeeupam ase equammeta or device which If a roof is installed without first obtaining an inspection, I agree to remove
emit haraNtwn air contaminant,as defined by the Bay Arca Air Quality Management
i<nier; all new materials for inspection. Applicant understands and will comply with
O Yes 0 N all non-point source regulations.
have read the h.mvious materials requirements under CIWAC,6.95 of the
CallfomW Ilealah k Safety Code,Se.lian,255115.25533 and 25534 understand thus
It
mhc hu' BJne nom cu nny haccn¢nant.tha it is tar respnnsibilirymnnufy the
m of squint which tnua he tact prior to ixwmna of a C'cniticnm of
`p y , 11 (1 ,M- Signature of Applicant Date
o— natha,drea ,en " L bI)".'KJ All roof coverings to be Class `B'm or better
OFFICE