00030013 (2) CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT CONTRACTOR,INFORMA_T�ION: 0C03 0013
HUILDINGADDRESS' 1a5t U�dMm 4.
`'''///����/// 0 I// //t�U�/J �{{/�//T/ /y,(f�1�/(/nVi( /�C SANITARY NU. APPLICATION UBMITTAL DATE
OW h ,22L i 12101 /a'/.�,�irl a.CG'V //VV• NIC 3/CONTROL#
A /
PH�N 2 NG�wa�r', ell 9Wys-X722 a
CHITECDENGINEER /// . /f,_ /f/j`1�
BULGING PERMIT INTO
UU
yQn
I.-�i LICENSED CONTRACTOR'S UECIARATION
z O - I hereby aRrm Na I w licensed uMar Provisions of Chapter 9(c ming Job Description
Oz[-� wish Satins 7000)alot v'ion 3 fthcBmim,hxhd Pmfxaions Cade, y'censeis
mfamm�eweRecL
a sa u<.g
y�o6�
'anlm
W'3 LL y Date f. <br
ARCHITECTS DECLARATION
1 malar and my plans shall Waited as public recolda
w 6 0 0
Li<enaed Roru,ioml
c ^
OWNER-BUILDER DE the ILATION
Commut
I-z a 1 hounc aRrm Nat I am exempt from the Commutes Cos License taw for Nc
x D following reaas- (Seaton 7031.5.Business and Raau.iom Code:Any city s county
t wmen regtril<w.amrb w eauw«iter,improve,demoim,m rewb am awewe S FC Floor Area Valuation
c.3- [,...it
e,alwrt to d�n o i,plimadin Communal.
Liceseiaw(Chamem y'
Nalneetcunuapursuant to Neprovisions 3.fi Co null..e Liaise Law(Clupter9 lI yp
(co he is ixemit gain anddoniaiii fr oeallegsimu end Pinkstone,An ions Code)or pN Number Occupancy Type
Wt he is exempt any ap m and art burs it the alleged she exemption.Any it prettily
of n _ -2 AV?
out mo than iv any dyed doll fm a permit xubjau she applicanno is civil awry or !J `�
t mom Nen Ove hundred dollen(3500).
p Larawner or Ne propeerr.mmy emPlaya,wiN w.ger uNeir mm<omaaaada., Required Inspections
wad W Wewmh.ved Ne awcturc is rotimcMed Law4 forsel<(sl,too an avvnimu
and Pmfesaiom Code:The aver th rco License taw dao naw apply to an owner of
gh
his O ny who bund,turpe tided than
Nerch i and who day men rent himself m through
his own however.
Prmided Nim puce rma"semanu art era intended a Offered for
We.If.however,Ne building or ren ofpr vine is sold within one year of completion,ane
her-Wilder will have the burden of proving Net he did nal build m improve for Pur- '
Pose of we.).
(]I,u.wmr of the pm,ed,am exclusively concealing with licansea caarxuhrs in
...true,the project Sec.7W.11miaua am pianist...Code:)The Contractors U.
me raw doe.Oct apply to an owner of property who Wilds or improves thereon,alb
who contracts for such exjeco,with acortrsctor(O licensed punaant to Ne ConUa<mrs
Cretins law.
I em exempt undo Sa. .B&P C for this mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 thereby amwam ren ad--awryosperjuryo.emsecmnowi.gworarsco: O
]'1have Pro will for
37M of Comm mCadc,swc fe WakeraComao-
anon,Os Provided for by Satan 3700 of the LeWr Codc,for the arfomnmla of the '
witch ill ountan issued.
m neve arta will IvinloinWMdw Compensation Insurarlce.as required by Salim
3700 of Ne Labor Code,for in, crycomna ofthe work for which this permit is issued.
My Wmkdt Compsmaii laxurarwecxum.dPoh<y;yT1r r<rO�D/U/fi'
Cartier: ( /AI�Q(-{ Policy No.:(!
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This recur Iwai not be eompined lithe permit is(orolch ndl ed dollen(Slam)
or Iasi
(certify that i I.any
mar. ,of Incworkfar whicht1.permi,isi,med,Isnail
rot employ any anon in any manner so as w become subject w tw Wmkere'Compcn-
pnionLaws dCalifornia.Dare
Applicant
NOTICE TO APPLICANT.If.air.making this provisions
of Labor
Exemption,youshouldMust
Wcma subjecttothe such ro Compensation provisions of to labor Cake,you must
forthwith comply with such provisions or this permit,Mll W domed invoked.
CONSTRUCTION LENDING AGENCY
0 O I hereby ffam that Vert is aconawceon lending agency for the performance of
Z r Ne teak for which this Permit in;waited(Sce.3097,Civ.C.)
Fes„ Landers Name
Uraler.Addres,
W 1 ceNfy Nat I have read this application and slow that abmrc informaid n is
L 0 correct.I again to comply wdN ell city and county ordinances anal Ras,laws relating to
.7 z building consonantal,and hereby authorise mprerenlotivea of this city in enter upon to
V 0 aWve-mentioned property for inaction purposes.
Iz E (We)sgme to save.indemnify and kap harmless he City of Cupertino against
O U lubilides,judgmcnn,town ink expanse.which may i.any war scram Meant said City
). W inennuqu<.ce mthe grain of s emot.
(• A. APPI.ICAN'I 1) )I Sl' ANU WILL COMPLY WIT'II ALL NON NI
L) SOUHCP.RPC .'S.
Signnurt.1A tic ten D Gam
RDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle hazardous morm.1 Re-roofs
as aennea by the Cul nina Marie rel Cade.Ceaptcr 9.Iz.arM Ne H W N and Saf<tr Type Of Roof
❑Y
Code,Section 0533(a)7 yDy. No
Will the applicant or fumm Wilding occupant use aquipmc.t or devices which All roofs shall be inspected prior to any roofing material being.
coal latitudinal air conumimnu as de0ned by the Be,Arts Ail Quellry Management installed. If a roof is Installed without t_irst obtaining an inspection
Di.ri<° �/ I agree to remove all new materials for inspection. Applicant
Y<s
I have mud Na hamJa,material, ,unser Chapter6.95 of Ne Cali- un erstands and will omply with all non point source regulations.
�I wyuirtlan
forms Health&SafclY C .Saaimu♦S 533 ane 5i1ox.I a, ifyM tMt if ins ai/j
building docs nor=,", utero art is mY mpanibiliryw tray the upant �/ (/
of Ne"uncmeal9 a <l'norm nx.,ar cc of a clic IC of OCC 011
' � Signature of Agv
t Date
Owner m amnodaed a ate
All roof coverings to be Class"B"or better
OFFICE