00030092 (2) CITY OF CUPERTINO PERMrrNO.
BUILDING DIVISION I PERMIT ick/1,N ,A TO ,IIhl'F f0 fM'/1��IOls1•: {�
BUILDING ADDRESS:
J {604) of tNI AR N V A
,p1 �/� /� fS 1107
/� SANITARY NO. APP,LLC/A(TIONSUBMITAL DATE
OWNry n)f 001 P, ��a' IIL/7 /J—�
hLn4 1 Liz
CONTROLp
PHQNE: 7�S-D rnAirllim 93`I33
ARCHITECTIENGINEER Q? / ' BU4111 O,I,Br0
aZw
.8m
I.,m LICENSED CONTRACTOR'S DECLARATION ,
o z�z,, 1 hereby aRrm Nat 1 am lianud render pmvisimn of CWpta 9(ronunencivg Job Description,
F=fro with Sation7m01ofDiviaion3ofNe Buaineeeem Profelai.v ardneyhomee ie
< in full force and cRus. /�(�
"'an"
CLu a IJc.p 1 1 II
3 U, Dale
� �—Canuamor 14.G.wag
C u.`O; ARCHITECTS DECLARA N
v�< 1 undeum v,hal
rmy plans W Dud as Public reonada
ce
gLicensed Professional
OWNER-BUILDER DECLARATION
E; ¢ I hereby SRLm that T am exempt from the Contractor's License Law for the
O frdlemmog reason.(Section 7031.5,Enlivens soul Professions Code:Any city m county
w6—R which rtqubm a Famous to construct,Mar.improve,demmiah,m repair any sumnme
3 Sq. Ft. Floor Area ala [ion
pathsoits censdpaha require,Me Applicant Me,Dohrfile.seLaw(Cemmem
Mat heislicevm pursuant 7 thepmvitlanaofthe Contractorsinne. License Law(ChapterCaper r -
that he isse xcepth Section s and t f basis
3Me al Busmen and Proficon.Any
vi Cade)m
Nat he is exempt N y.ppi and the burs rut the alleged exemWiov.Any riobuon of 3 I N bar , Occupancy Type
Seaton Room ire any applicant for a pemut wbjata dm applicant t...ivil petWry of a
not marc Nan flue hundred dollen(Sem). J
L]Id.M.wexk, ndMMe renct mYemployees withwages m Ne(See 7W.Box.n, squired Inspections
ssiland duthcwors Code: he Co ractornot inmmnseel Law ors We(Seetoan,wneku '
and erofualone Code:The Con flumes,"w law does nen apply s lf comer of
properly,who build,or improves Nmon,era who don such wort himself of through \ /
his awn employhowever,the
provided then such mentis old within art nen inmmed m.Rama for V .
Werf,haweveill how Me8men offrvint isan hedit er Wild car
improve
le don,the r\V�
owos,rbuilder will have the buNcn ofpmvia8 Net he did not build or improve fm For.
Ej pose of sole.).
1,n owner of the properly,,not Bull.exclusively contracting wod:i T e Cwno-aoon t. '
cc.La the n,.1 ISec..an wnof rope Py.1,u v Cade:)The Cantrare d
cave Law does cos apply to ts owner m properly wce Wilda m an,.the
d
Liens.Lads for such protects with acanwctm(q licensed punumt m de Canwc
License Law. - '
❑I eon exempt under Sec. %B 9 P C fm this won
Owner Data
WORKER'S COMPENSATION DECLARATION'
.1 hereby affirm under Forcedly of perjury ms,of ds,following declarations:
❑those em will vmioWna CenificareafC...t m ulf-inmen f n WorkeYa Compere '
I,
as provided for mi is
issued,37m.(the LeWr Cade,la Ne performantt of Nc
Zen
which Nia permit is issued.
❑1 have and will maintain Woncer'a Comfxnntion Imurnnce,or required by Sasi.n '
37m.f Ne labor Cade,for Ne perf.rnmcc of Ore work for which this permit is learned.
My Woke�'aF pevation I�nvice carries and Policy
FOR,No. XSX71
CERTIFICATE OF EXEMPTION FROM WM W E's
COMPENSATION INSURANCE
(This sation oeedtrot becompletW if Ne Permit is for oro hurrNeddollareni I
or tool
Toy ary,Na in the pertormne,.as
hewn,which thiapermit is leen shall - ,
not employ 0, .on is any manner w n m became subject to the Wuhan' mpem '
noon laws of California.Dam
Appli
nt
NOTICE
NOTICE TO APPLICANT If ager making Ni,Certificate of Exempt n,you should
haom subjat to dm Worker's Compenmtion pmvisiov of the LeW ode,you must
fodhwith comply with such provisions or Nis permit shall be dee revWed.
CONSTRUCTION LENDING AGENC
Q Q Thereby atfrm NU Nem is aconstvcuon lending age yforthcperfomtanceuf "
z Ne work for which this permit is issued(Sec.MAP.Civ.C.
EyEff Undoes Name
a, .lander',Addres,
W Q 1 certify Iden 1 base read Nia applicnion and oro Thal the above information is
d wrest.l apron to comply with all city and c.umy iru. ape sum lewe rattan".
z building construction,uW hereby anhodu repro nsaivas of this city to enter upon ds,
U 0 above-mcmioned propmy for inspection pu
P (We)agree to neve,indemnify and k harmless Ne City of Cupertino against
U liabdiuer,judgmena,creta and expenses which may in any way we=against laid City
} fz1 in consequenm of de granting of this permit, -
FLy Qr APPLI VTUNDF:R. ANDS AND WILL COMPLY WITH ALL NEIN-MINT
Sig
name AppliranJConuector I Iffate �r V
HAZARDOUS MATERIALS DISCLOSURE
Will the apteliconsor future Wilding owupmtome or handle hazardous material Re-roofs
as defied by the Cupvrino Municipl Code,Chapter 9.12,and Ne Health and Safety
cmc,Sectionzi532(na Type of Roof
❑Yee IF
Will the applicant or future Wilding occupant use equipment or devices which All roofs shall be inspected prior to any roofing material being
cost bazemous sm contemn rwmu fired by Ne Bay Area Ah Quliry Management installed. If a roof,is Installed without YY-first obtaining an inspection
°``� ' I agree to remove II new materials for inspection. Applicant
❑Ya No d
I Ms.orzd ted h.urdoua materials un ,tan w 11 cam 1 with all non pointlour a regulations.
� regafremenmrnmercluper69sofNcGli. P Y P g
mu HeeIN&Safety C Savors]5505,fare eM 2553,.1 understand Nat if IM ,
M1uildin dy e¢nun4 Nat it is my rtepovibilitym aify eoaupant t/pr►l1I
oftheg}�hiynI be m}pdamidawntt of Cryo 9f�ggcu y.
�YN I A K� a 3� d� Signature of App icant Dale
fhvnc "z Dam
All roof coverings to be Class"B"or better
OFFICE