00050043 (2) CITY OF CUPERTINOPERMI'I'NO.
]BUILDING DIVISION PERMIT CONT t_'G-TOR-H?Fy -e ,A TI'O�,N. oOO�• f,)b� (3
BUI/31;G ADDRESD f � /� � p1 `B
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SANITARY N0. APYLICATI=N SUBMITTAL DAT[
S ova
OWNI;R'SN Mli�4 ye 38Hy �pn`r y 44 NIC
COMI'ROLM
P ION, F 5 A/'I V �Sr
- 365 z.�c. 6goZ8 /
RCNI'TECT/F,NGLYEF:R BOLDING pERMIT
�00
rv' LICENSED CONTRACTOR'S DECLARATION
Z 0= I hereby affirm Net 1 am licensed under provisions of CNger 9(commeming Job Description
with Sation]IXp)ofpivisian3of Ne Buainwsend Profeasiom Code.end mYliantt is 1
't in ran rorceud.Rat. G bra pI'p��, � 'lAe. .I4Cf h1+P�T
s i JJceese Clsu Lica a ►�+%r
y o w f Date-5Y&J9A Convector
_u O V ARCH DECLARATION
za G 1 understand my plans shall be used in public mounds
i SCo Uccumcd PmfcuimW
OWNER-BORDER DECLARATION
1 hereby elfirm that 1 um erempt from Ne Commamr's License Lew for the
F following reawn.(Scomm]031.5.Business and Pmfc.m.Cade:A,city or wary
3$ which tcquims a Permit in consumer,alar.Improve.dcmolleh,of mpoir any sumona a Sq. Ft. Floor Area Valuation
prior to its nauance,also nobodies the applicant for such prmdt an rile a signd rotaunt
that he is licensed pursumn to Ne provisions of use Connector.Licenu law(CMptar 9
(comrmncing with Section]0(0)of Division 3 i fthe Business and Is ofeeai...Cod,)-
WI h<is excmq therefrom and Nc basis for Ne alleged tampion.My viotau'w of ' 2 0 Q Occupancy Type
Section 7031.5 by any applicant fora permit subjects the applicant to a civil pemlry of
t more than five hundred dollars($500).
I'm.,of One proam'.r my cmPloyua with..'es as dainolc c mom Requir nspections
willdothework.and Ne...mrsisndinerdMmoflcldfm We( , Ofa,B-1—
and Pmfeuiom Code:The Conuxur's License law does, y t.an.sena d
q.prny who builds or improve.dmerc.,and who dace such work himself at thtou¢M1
his own employees,Provided Net such improvements ars not intended or offered for
We.If,howeverthe building or improvement is sold within one yearofeompluion,the
owner-builder will have the bathe.of pmvm,that k did nm build m improve for pur-
poseI,aownea msme
r.(Ne Proprny,un exdu.ively emvecmin8 with licensed convecmn to
c nswd the project(Sec.70ea,Business ad Professiom Cade:)The Co...costs V- /
came law does ort apply t.an owner of property who builds or improv.thenwn.and O
who connects for such projects with acwtem.r(s)licensed pursuant to the Contactors O
Lu,".Law.
I am exempt under Sec. .B 8:P C for this rcuun V
Owner Dau
WORNLER'S COMPENSATION DECLARATION
1 hereby affirm under penury of perjury on of the following declarations:
1 hove ebromu
nd will m a CeAu u
fcaof Consent self-insure for Worker'.Comprn.
P
u provided for by Salon 3]00 of the labor Code,for the pertomurRe of Ne
work for which this permit is is.ad.
I have and will maintain Warkres Compensation Insurance,in requited by Section
3]Opof the labor Code.fm the grto ante of the work for which this permit is issued.
Ca i a oro sari. wrgn corder and Policy rymQ 1 i4A
Canine O8 Policy RONo.:/µ'20e
CERTIFlC OMPE XEMPTIINN FROM RS'
COMPENSATION INSURANCE -
(Ihia uxdnn rad fid be<ompleudifthe pemd is forest,M1undrcddollm(5100)
or Icsa.)
K.WEcw.,O,,,,AN,,.
'fy thou t pr ormaarof ewmkforwhich Niaprmtit isivued,lshall
nyanntobeta secvbjatwtheWorker'Comgn-
o I[ager makin eniriceuorEmpuw.you should
s m the Worker. median
ns of Ne Labor Cade,you must
forthwith comply with such provisionsor Nis rmhsshall be dared mvoked.
CONSTRUCTION LENDING AGENCY
Q 0 I hcrcby affirm Out there is is comumcom kini,ii,ocy for the d...f
Z Ne work for which this permit is issued(Sec.3097,Civ.CJ
Lenders Name
(Y > landre.Addreaa
LT7 ^Q I certify Nam 1 have read tris application and sure that Ne above information is
Paconal.I agree m comply with all city and county ordinances and state laws muting m
U Q build. ......struction,arta herby w.m.nerepresentatives of this city m enter upon 0u
above-mentioned property for inspection Purposes.
(:. E•, (We)spree to ova.indemnify end kap harmless Na City of eugnimw.gairmt
C U liabilities,pdgmems,toss and .prours which may in any wey arcrea8alnst said City -
;,a W in conserve a I the granting of this vomit.
[•+ Om
APF JC I' 'llligtil' )SANDWIILCOMPIYWITN ALLNON-POINT
u3U �T IIATI 5*/lOO ,
U Z S' sal Applicavecn Con / Das
N S MATERIALS DISCLOSURE
Will the applicant., building occupant rime or handle harard.us metered Re-roofs
as defined by the Capcnir. nlcipal Code.Chapter 9.12.and the HGJth and Sdcry Type of Roof
Code.Section T55320,)? yp
❑Yea on
Will Ne applicant or future building acupsm use equipment or devices which All roofs shall be inspected prior to any roofing material being
crit heuNous air conarninams as defined by the Bay Arca Air Quality Managcme t installed. If a roof is installed without first obtaining an inspection
auric'' I aree to remove all new materials for inspection. Applicant
U Yes No
`
I have mad Nc haurdaamw materials rt monneens under Chapter 695 of the Cali- un erstands and will comply with all non point source regulations.
tomo HW th h t ode,Sections 255D5,25533 and 2553x.1 undermined that if the
huildingdaa ndy Nveau t,Nm it is my responsibility in nctify the occupsnt
of the cher nt a..of.Cenificeu f WrRY.
06 Signature of Applicant Date
Ower o zed gent as
All roof coverings to be Class`B"or better
OFFICE