00050061 (2) . CITY OF CUPERTINO - ,f, I. ®� ^h PERMITNO.
BUILDING DMSION t. .• - PERMIT. . • f f i e I t, . �I.JIJ yam/^
BUILDING ADDRESS:
15I, � �� _ '" G -• SANTTARYNO. APPLICATIONSUBMMAL DATE
�!�/i/ate SOit/ SkE[ ''E
O ER'SNAME '` ^ _ ... -,i� � l'�. �r
NIC CONTROLpPHO L:
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ARCHITECVENGINFPR ' .. • s B 1. I T g.0
LICENSED CONTRACTORS 1)ECWRATION..
1 hereby all,.that 1 am licensed ars pmn.inew of chapter 9(eammenntng 'Job Description with Section 7").fDElli.3 of the Business end profession Code,and my license is I I•,_ a<
¢y '-) infull fo avid eR<ct /(O, Q)/,00v•�
g C Dole Class �f Lic X 1
` 3 N Dat used
url
s•u.O� _ ARCHITECTS DECWRATION 'i J
G� 1 understand my plan shall be used m public«cordo _ •
Licensed Fmilerimulds
OWNER.BULLDER DECLARATION Ell
r r+,
1 hereby affirm that I em exempt from the Connector,License Law for the
OFollowing (Section 4431 5 Business and PmRauon Code Any city or county
d which rc9 leirnd to mnsnuct doer,improve,demolish ar repro,any.. Sq.Ft Floor Area Valuation
prim w its issuance,deo requires IM applicant for such pemut w file a signed atas<meat
Nat he ie licemed punumtto Ne provi.iona of Ne Conaactors License Law(Chepee9 s _ •1�,�
(comm mgwit Section T000)of Diviai for me
BunascpM P%(euton Cade)or , `JP
to be i xempt Nmcfrom erd Ic best,for Ne mleged sae a on.Anr v 4:n z.. APN Number - Occupancye
Sectio ]0315 by any applicant for a p rent subject,die eppl c t ln e e'inl pen a( -
t more then fJe hundred drllers(5x00). 4+ ✓ +
1,as owner of da,propeny,almY emPloyae colied wagesutheir cote comport 'an, - _ RC SpeCh On$ -
willdoNework,and theetlucture is notmentsdoroffmceiforsale(Sa.9044,Boai >' _. s ti
and Profusion Cade:The Convector's License Law does nm apply.it,an owner of `
• property who build,or Improves thereon,and who does such walk himself or duough r - •, r ,
his own employees,provided Chet such improvements arc not intended m offered for, - a
role if,however,thebuddmgoirmpmvementlasaldwithmme yeerofcompleuogdw , r
\\e`owns builder will have the burden of pmvmtl Nn be did nil build anmprove for pur-
` Ea f sale).
owner of the property,arreaclmively convecting with licensed am.in
wnuvct the project(Sec.0644,Business and professions Code:)The Ommour's W.
cense Law des ooupply to a.ow'ta,r of property who builds R improves Iherann,end
Who corrects for such prejectswuh econarsom(s)licensed pumma to the Carmichael
License Law. -
-' ❑tam exampr under Sec.'• ' B&PCfordu.owE
WORKERS COMPENSATION DECLARATION e V /
I hereby affirm undm penalty of pepury one of the insuremg declemEs Co
❑l have and will maintain a Cemfi are fConsenOo wlf.mwre farWok r Compen
wuun,ea provided for by Section 3700 of the Labor Cadc for the performance of the
alk for which 61.permit is issued.
❑I have and Will rostrum Works COmpcnsauon Insurance as requhed by Semi n
3700 of do Labm Code,for Oa,perfonnerve dal work for whichth,a permit to issued.
My Wod:err Poll
ryncm ✓ my No.:
C RTIFICA E OF EXEM ION FROM WORKERS +
". COMPENSATION INSURANCE
(1his easomnneednm becomplouldNei permit humehoo ieddollen($100),
3eenify Wtin Ne Ndomnanmof Newmkfmwhich Oispemutisiasued,Ishdl,not employ any person in any mmner an as to become rubjeci to to Warton'(7ompan-
section lewwf Cdifomia.Dau _ -
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should r '
become subject to the Workers Compensation provision of the Labor Cade,you must - -
forthwith comply wit such provisions or this permit shell h domed revoked. - -
"v• .F
r
CONSTRUCTION LENDING AGENCY ` . •I'
0 IMrcbYNretan Nemneconeweu mending.germy forthe pertomwice of )'f 4 "
spa
the work for which Nes permit is issued(Sec 3097,Cie C.)
Lenders Name r
ya Lender.Address _ u' o.
{ra Q I certify Net 1 Mve read du eppl¢at end Imo Nett above tnfomuuon is Nn
comat.l ogres to comply W till c1y d aunty d'vnce sure laws Rlai g to
building commotion,and hereby th rcpresenui vas t is city w enter upon the
U above-memmm property forma, cu P. man. /l� - .
W �a (We)agree to e,rode ify nd kap hmmle h City of Cuperuna almost' ,
0 f�1 liebdiucs Jm
tdgmes'cwuatd spa .which m.yn y eY scene against mid City,
y+ r�
SIII�AN`l
ceofOwBmntin6 f Permit.ONDERSTANI SA )WILL COMPL ITH .LNON.POINT
REGULATIONS.
r gig of ApplicandComVilind
DateMATEIALS DISCLOSUREirbuilding occupant store or handle hawdem,materiel Re-tGD $fi ed by the CuperuniCode,Chapter 9.12,and to Healed and Safety - -
c ecuanzss32(a>P '• Type ofRoof -
❑Yes No • ' '
Will the applicant or tYWR Wilding mcupent se eanipment or davicea Which All roofs shall be inspected prior to any roofing. material being
emit hazardous air con[uninmu to defmed,by the B Arc a Air Quality Management installed:If a roof is Installed without first obtaining an,in"spection
°`a"`"' I a ree to remove all new:matelE for:inspection.'Applicant
❑Yes id. 25505,
+ _ g
Ln;r<rcad do hive, a ` understands andmill comply with all.non point'source regulations:
requireme u under Chapter h.95 of the Cali. r7
salt R Safety Code25533 25534.L understand Net if Ne E ' r
h lith dors nm currently bat it is my amiability w notify the occupantSuiremem.which mof a Cmif is or upancy.. .1
Sigtiature,of'ApplicantDate.,. -
rmr r utodzed agent are. + „•, � ' .' -
All"roof coverings to be Class"B"or better .
OFFICE