00060070 (2) CITY OF CUPERTINO '}- ' tt PERMITNO.
BUILDING DIVISION PERMIT CONTRACTOR-INFORMATION:
BUILDINGADDRESS:
X;
f n-�f G/A�nr�� {�f/,�,p � �B s/J��,.�. SANITARY NO. APPLICATION SUBMITTAL DATE
OWN.R'SN E: �/ S7J Y/�"�` cl�� e -
qq ) N/C CON ROLX
HCIITECf/ENGINhR BULGING PERMIT INFO dvY.
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LICENSEDCONRACTOR'SDECLARATION
I hcmbY aR that I am liccnad oder Provisiom of ChepW 9lmmnn,mini lab Des np I n
Y.�J with Sectim'!00%afDivition3 ofthe Buaimxa and Pm(essiom Code,admY littn;is /ff �L��j �7,� J�s \��
¢¢ r a >
in full fortt o cRm _t/
D y U Licennc Chu�-;9_Lic.g
'�3 B Data ria/ Contmcwr /.�
.B O ARCBITECTS DECLARATION
�¢� I mndentW my plum twl x mxd m wbhc reaoadt .�
i a o licnnsed Rofcxsio u"
-^m OWNER Bwne,to DECLARATION
I—i a 1 hereby.(B that I un eBusi from the fmia rs :My C Ino M thee
E s D followin8 auson.(S«tion]031.5.Busiucu W Rofaiom Code:MY city m mumy
3$ which its iou a pemit ro comwn,JW, demolish,fi repair any aremrt Sq. FL Floor Area Valuation
prime,itsissuan Fireman
also requites one,Whereat for sucho mit Lice ssignedrWetmnt
that M is littnad pursuant w the provisions of Bn,Convmtoh License Lew ICltapter 9 0
(outsmarting with Seetian 70W)of Division 3 ofte,Business sd Rofusionx Cade)or APN urn e ecu ant T
that he is emmpt therefrom sd the basis for the alleged!exemption.Any violation P Y YPC
to
Section)031.5 by any aPpltcmt for a permit subjects the applicant to a civil m or/
pt.ort than five hundred dollars($5001. o
1,"town,rorthepromnr.errtaremployee.withw.geaasthei...lecommn don. Re ed Inspection
will dothc work.inside,structure is awl imcrdcd in offered for Wa1Sx.1061,Bus
and Prolamm"code:The Cmdercaor'.Liceue law don awl apply to an owner
his o nr who builds or sided to such and who fines ouch work ed!of of through
sq.own ooesertts,m^vidd a i such improvements tic not iyeaded m otretd Tor
W,.If,however,the building or improvement is hold within one yeas of mmpldor par-
'.
ilda will bass the burdenof provini NatMdid ret buildmimprove(orpor-
pou or We.).
❑I,u owner of the promny,ren sinus and conmismor with:)Thidormsaetors -
omeLatheesnor apply
Loan owner
sod Professions Code:)The Contncwrs nd 2,`�'/`
cents Inodaonmapplymm its arofproperty who buildsor improver Canare,and V
whocontractsLaws for such proletts with a conttmtor(s)licensed pursuant to the Contncao/s O
License
exe O
❑I em<xemW a^der Su. .B R P C!or Nis reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hneby affirm oder Penalty orp ijury one of B.following declaration:
have and will maivuin aCenifica.arc.w sdGimurt fee Worker,Compaq.
tion.as provided fee by Seetirn 3100 of the"We Cadi fee d.pefomurc<of the
wmk for which this permit is issued.
have and will maintain Workers Compensation Imurmce,as requvd by Satire
100 oldie Labor Cade,for the performance oftM week for which this Permit is issued.
My Worker' Cpmpe�ti Insurance carrier and Policy num"
em�.3
Csmen JF�wQ n Policy No.: 4 �
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section mead urn he completd if plc m orm is furore hundred dollen($100)
re Ina.)
I certify that in the pe fomunce oras,weak fmwhi,h thi.mmdt is iuved.I"I
not employ my person in my ma rcm u r to Mame mbjmt to the Worker Comper-
cationlawsofCalifornia.Date mar
mar
NOTICE TO APPLICANT:If.after making this Certifies.of Exetspo or.you should
become subject w the Workers Compensation provisions of the Labor Code.you must
forthwith comply with such provisions or this Permit shall M d«md revokd.
CONSTRUCTION LENDING AGENCY
O I hereby r ffm the Ncre is a construction lending agency for the performance of
w.Z ythe work for which Nis pemil is i...d(Sec.3091,Co,,C.)
lander"Nene
a > boutons Adds,
EI entity died t I hanal this application and We that On,anew iaJomution is
A. cat.I agree to comply with JI city ad county orclivncos and sulaws miming m
Z building corammm.ad hereby mthow,farp..menw.of this city to an.r upon BIC
C.7 0 aMvrmentiond propcny for inspection purposes.
Lu E.. (We)agree to use,indemnify and Peep hornless Bw City of Cupertino agalmt
�J
liabilities,jdgemonb.cut.adamnms which may in my way meme,rumt said City
in consequence of the granting of this permit, v -
Fr APPLICANT LINDERMAN DS A N D WILL COMPLY WITH ALL NON.I1)1 N
7) SOURCE REGULATIONS.
~ T aU * 1
Sigmtum of ApplicanUComrmtm Data
HA]Afunme MATERIALS DISCLOSURE
WiIbythe Cupantor future Wilding mWPmtswmm handle hawdou.ma.nal Re-roofs
C del rad by the Cumnim Municipal Code.Chaps 9.12,and!the Health ad Salary Type of Roof
Code,Smuts 25532(")' YP
❑Yes ❑Na
Will the applicant of future building occupant use equipnn,m tar devices which All roofs shall be inspected prior to any roofing material being
omit hauMous air conmmimus as defind by the Bay Area Air Quality Management installed. If a roof is installed without first obtaining an inspection
46 Dltmier0 Yet ❑No I agree to remove all new materials for inspection. Applicant
Iha,read thee hsvardons mateuals.gmi.memenMe'Chapter 695 of Bac Cali. understands and will co 'l with all non point source regulations.
roma Health B Safety Code,S veru 25505,25533 and]553x.I undenund that if tho I.
Wilding cleats Wicurrently how,a lomat,that it is my responsibility to wesdY the occupmt /
of therenui amen s which most M neat priorto issuame of a Ccnifinm of Oacupemy. _
Signature of AWiclint Date
Ower or authused agent Data
All roof coverings to be Class"B"or better
OFFICE