00030088 (2) CITY OF CUPERTINO PERMIT NO.Q�
BUILDING DIVISION PERMIT CONTRACTOR IN, ORMATI,ON: 06 36� v
BUILDING ADURf55: 1lyy'('��'V ate/' `, MA l� ,^�� #
`� b2 RtVGF V 1E- I G�_ 15'` f`�t L 1�/J5� SANITARY NO. APP KATIJO(N�SUBMITTAL DAT
(1W I/_J JO> �N�UsL_ _ Iv�Vl ✓� % 7��0 ^
NIC �j CONTROL#
DN
1>2-14-
4S�kN ��S1L ❑ 0
ANCHITECTIL'NCINEI:R 406- 4- a a —9 320
OULDING PERMIT INPO
o Z VVt�' JL 4 C7/
1-N" LICENSED CONTRACTOR'S DECLARATION
Y O�,= 1 hereby effort that I w licensed under Provisions of Chapter 9(camnae«ing Job Description
F=1— with Section 7000)afDividon3of the,Business and Perfewnns Cade.and any license is //a a/ �/�/�a (� X�` 1
Q Y J in full fore.Nd eff a. f2' N PrI� ✓LSO p-S / I f At2m�
oda License Cls. Lic.X
m
3 4 H
are ^�• endo
ARCHDELT TION
rid my plan el c rec«da
C
to'n z Garsted I'Manioffi'--�
v Tru OWNER- ORDER DECI kRATION
1->a I hereby a am eaemq fond the Courtrai License taw fon the
S a following mason(Section 703 I.S.Business and Profession.Code:Any cily«county
iso Cm which receives a pnit 0 construct alter,improve, mpei
demolish,err mr any awcwc S FL Floor Area Valuation
3 qi«to iu ismana.dm mquirts 0e,applicentf«such peanut earkaaig«Anemment q' / OOO
thlal he is licensed Prususnt m Ne Provisions tuf,h,Canaan&'Lica ase Law(Chaga9 �I
(camms«idg will,Section 7000)of Division Sof the Business and Profusions Code)or APN Number Occupancy Type
that have exemq Ihemf..W the basis far the alleged exemption.Any valetion of ,y
Session 70313 by any app&ant fare pcmdt mbjecu than yryfcent to a civil penally of
of mart tom five hatdrcd dollars(3500).
.i Lo the work.the pmsany,«myomployav wimwaguu Heir rule 701congeoundar,
strues Required Inspections
a.illnd Pr the work,and the he C.o is not kmddns or offaw nul dos rate(Set.o an easiness
aro Profauom COM:The Convertors License law des not apply to an owner of
his o nY who builds or imgovu thereon,add who does such wand deed err or thmuBF
sal own employese provided or improvement
such mentis sold within
K ort intended re offered fon
.wou-NildIf,however,Inds buil dingmimprovamentithat he did non deer fcpucvc farar- ��
owner-builder will have the burden ofprovin8 that he did not build or improve f«par-
pose&de.l.
L u owner of ere,S..7 •,H eachubsel,coahacung with licensedThasCon-'&-s to `_S/
cun.Vua d prones,(Sec.vans,Bmi«fa aM rty who Wi Codes The Conaset&a rid
canoe Law dose not apply to is owner of property who Wilds or improvesuse Carton,and
who contracts.L .for such projesa with a conwet«(s)licensed purswm to use Contractors Q
Lkanse lion. O
❑Ian eaemq uMcrSes. .BQPCfa this rta.n '
Owner Dau
WORKER'S COMPENSATION DECIA ATION
1 Wert&,eRort under penalty of peoj«y ane err Cro fallowing dxlaranau:
1 have and will makstfn•Cauficert ofCan.al to setbin.rt for Workers Compact-
nine,
as provided for by Section 3700 of the labor Code,for the perfomu«e of the
stork f«which this pound,is issued.
1 have and will mainoin Wonders Compcnsetion Ivusawa,as required by Section ---
3700of de,labor,Code,for the putomu«c of the,work fm which this permit is insured.
My Wonders compcn.tion Insurance carrier add Policy number art:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION MOM WORKERS' _ ,
COMPENSATION INSURANCE
( s section need t&M completed Bids,pc ou t is(w ane hundred dM lana(S IOC)
m lase.)Thi
I certify that in 0e,performancethe work for which this pe. is issued,)shill
rot employ any person in any men«,an w as to become aubjat to the Wonden'Corbusier-
Applicant
ofCsuilomia.Dare
NOTICE
ant
NOTICE lbi APPLICANT:If,afar making this Croons of of E tion o d you should
hesortch ona Ply the Worker'.Cd..or is person
Thal of Ne Labor Code,you mus
forthwith wmply wind such gvvisians«Ctia pump.IuR be dam&revoked,
I
CONSTRUCTION LENDING AGENCY -
0 p I hereby alRrm thin lhereis 9],a construction lending agency forthe perfomaoce of
Z da,w«k for which this pepersonspersonsc caned(Ses.30Co,CJ
2
lenders N.
> Iaods Address
W1 certify that 1 have reed this application and sum that the above infmowtion is
Fr l2 C.I.I agree to comply with all city aro county ordinances and note laws Mating in
:D Z building eonnwemn,and Washy sound.regetrnunvu of this city to ender upon Ne
V Q above-mantionsd propeny for in epecaon purposes.
Lar F (We)area to nave,indemnify and leap Issueless the City of Cupertino against
0 U liabilities.judgmema.ma6 ata e.pen.'which may in any way accuse against said City
�., W in consequence of the6 "peanit. -
E" APPLICANT UNDERSTANDS A. PLl'WITHAI.I.NONdVINr
90UR2SU IONS
Si,i amreerr t.ct I let Aj
ca �O HAZARDOUS MATERIALS DISCLOSURE
�� --
Will due applicant or fume,budding occupam store or handle harandous material Re-roofs if
as defined by the Cupertino Municipal cadet Chapter 9.12,and the Hadd,and Safety Type of Roof
cane, 0YeszsmaoYpY
V<s
Will the applicant or future building occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being.
aviI haserdous sur conwninmts as defined by the Boy Arca Air Gustily Managemcel installed. If a roof is installed without first obtaining an inspection
°�° `' I a tree to remove all new materials for inspection. Applicant
❑Yes I4No
I have read duW nod..material.rtgaiamenu adder Clover 693 of the,Cali. un erstands and will comply with all non point source regulations.
buHI &Safe 325]6uMmond Nel if theto vew0xpoildin8 non risibility
to if,the,occupant
of the, wNcWt aofeC ific.af supae,y.
W1,11 ZfLLJ-- Signature of Applicant Date
was or au 'r en, as
All roof coverings to be Class"B"or better
OFFICE