00020047 (2) CITY OF CUPERTINOPERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR'INFORMATION:, 0O 2 O
BUILDING ADDRESS: &1/�
11&71 "�eyrgzvr WA FEE NrE'R/�T�ee/6 /G�',,N�i..y y�)/f./ry/�{n/•e. SANITARY NO. APPLICATION SUBMnTAL DAT
-D Elt'SNAM E: /ehlizi / 7O G • aa•Qj/! T//• -2-
NON arae da/ 'A 959ys N❑ CONTROLp
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ARCHITECT/ENGINEER BULDINO PERMIT INFO
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F•�'^ LICENSED CONTRACTOR'S DECLARATION
z o„ 1 hereby shorn the 1 Am licensed under provision of Chaplet 9(wmmelcing Job Description
FZf-m wiNSation]000)af Division3or NeBmincu and Profeviom Code,and mylianx'
ce < infullforteand e_I S7 GUQ�er HeQt9r
infulle la Liar
is 0u.y Dex Conlmxur
ARCF[TT' g DECLARATION
s ;,� 1 nneeawd my plana awl x axe.,puMm memdA
HMF
X R z Licensed professional
W_u OW NErm exempt
DECLARATION
7 Z a 1 hereby sScm Nal I am exempt from Ne CoCock:
:Any c Law for the
s O following lesson.(Skettion 703 1.5 Business and prosecutors Code:Any city a«unry '
i which requires a permit a comwcl,eller,impmvo,demolish,or repair any seucone
3 prim to in issuance.Also"Vim ate mm applicant fee such peut Elea6'radetaten¢nl Sq. FL Floor Area lDn
/�J Valu/a�tn
dual neuli«mea purnwt101ne provisions or one Canteamor,Li«fix Lew fCNpxr9 /�(/• (/(/
(ran he isixewimsecdanrondRe, formfNeRmiexe ptionAnyameoamm APN Number Occupancy Type
Nal io is exempt Nae from end Nc buffs for Ne elkged palmation.Any violation of P Y YP
Section]031.5 by any red coo for a pemduubjau oM1e applicant m a civil penury of S/ ��/
Ann mom Nen Aft hundred dollar y Amo).
Leah week,one prapeny,mmym imerae with waguulneiSec.7W.Business Required Inspections
will Wthe work,And ete awmort is ren.Licensmo wdos ala(Ser.]014,Ownircu
And Peofuso b Code:The,Contractor.thenr'A License do does w apply to if twos'Of
through
-
binprepefly..who beim.a fitted ds,AuChn,aur who,does such wok Moult w 1ned for
his Vwn employ«a,pmvidW Thu such impoveolld w etc rot inxldW a offered for
ale.If.however.ate in,the8orimpmvcmin is sold withinooeyea of«nlple for she
ken WO).will Mrc the WWcn or proving that fie did not Wild a improve for pur-
pose of talc.).
L u ownerrm the property,erne Sanas cul contracting with Beamed conteumn in
C.1 Ote project(Sec.7044,Retsina aur limitations Wild,
Code:)The Contactors fid
cense Law deco Imo apply do eo owner of popery wed Wild,or impto the
NAn.r.and
who ernlew¢for such prolate with e<onleeelm(s)IieensW Panuenuo Ne CanvedMn
[3 1 Am Law.
O tun exempt under Sec. .BkPCfee Nis lesion
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby arm under pemlly of pc Jury ore of the following declueliom: v
1 here ted will malplaln eCeninute e(Cotvml to self-insux fm Wokcrs Compcn-
salio t.as provides for by Section)]00 of the tabor Cadc,foe the performance of th<
woetdorw,1z Nis ninsil is iuueL.
Ipjyrt have and will meinlsir Walker's Camn.f0r,w rk par who h rtquimd by gallon
lb fthelsWr Cade,for Ne perlomunce of Ox work fm which Nis permit is isxed.
My Work rsw f�y[an� u
c Carrier and policy n r
CimicoEVII7,, I'i�sks fJ Policy No.: � In��ns
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mi,xetinn need Am beeompkehl ifate permit is foro«hundeW dollen(SIM)
Or less.)
I certify that in the Any otmenceof the wok for objects to thepermitis iuuW,l shall
nalneCMNOYLaw of personin any menncr so as to became•uhl«d let Nke Warkem'Camper-
Wine ant of California.Be.
Applicant
NOTICEub APPWeANT If,atomreeking this provisions
of "law Code.
should
W«ta,comp y it Worth re Compensation previsions of thorned
Labor Cade,you most
foMwiN comply with such provlsionr or Iris pemlll shall be tamed revoked.
CONSTRUCTION LENDING AGENCY
O 0 I nncby afirn dual Neve iso conswction lendingagency,far Ne perfomun«of
Ne work for which Nis permit is Owned(Sec.3097.civ.C.)
Lender's Name
ye 1.Ades',Address
W 1«nify dui i have rend this application and sate Nal Ne above information is
R• ^� correct.)agree to,comply with ell city and county ordinances and suer laws xlating to
rti Z building conswction,and hereby euohorix representatives of this city to enter upon Ne
U O above-mentioned property for im,ec6an puryoua
La, t: (We)agree to Assn.indemnify and kap haradeas the City of Cupertino ageimc
O U Inabilities,judgments,cmuand eApemu which may in Any way acme Maim,said City
�s W in consequence of Ne granting of th amid.
F ti APPLICANT UNDERSTAND'.ND WILL COMPLY WITH ALI.NON-WINT
V z
SOURCE RIiGU1.1h NS.
r. 46
Signature al Applicc V m
HA OUS MATERIALS DISCLOSURE -
WillNeappli«ntm Net.Wilding«capes same or handle nuudw6 material Re-roofs
a,defined by the Cupertino,Municipal Cocke.Chapter 9.12.And the Health and Safety Type Of Roof
COCA,See..255321e)] / YP
❑Yes Vo n,
\ WiillteApplicant rfmumWildingacupmduxequipmenlmhvi«,which All roofs shall be inspected prior to any roofing material being
Abecndom an cOnlamitara As defined by lM Bey AAt Quality Management installed. If a roof is Installed without first obtaining an inspection
iA°oat' rte I a ree to remove all new materials for inspection. Applicant
Ven
1 erstands and will comply with all non point source regulations.
Ihaverutfhamdon,..anrequimmenaunderChapter&95oftheCai- un
` (ninon Health&Safety Cade.Sections 25505.25533 And 25536.1 undeMadi Nat if the
buildogdasnmcurent heveamnenL Nalit is my xsponsibiliry to Amity lhemapano L (��
Of NC R%IYlrtmtle0a wnl muslWnxl pllor to i6eueMe ofaCMift de ofO ea My.
Signature o lies t Date
Ow«r m eulhmized a d tax
AII roof coverings to be Class"Bfe or better
OFFICE