00030149 (2) CITY OF CUPERTINO PERMITNO.
BUILDING DIVISION PERM T CONTRACTOR INFORMATION: ,Q,0O 3O J L/ G
BUILDING ADDRESS ' � Soc//// 7� = I
Q V (s LJ SANITARY NO, APPLICATION SUBMITTAL DAT
C— 6 / ��� ��N�� NIC CONTROLB
ARCHITECTIE-NGINEEN ��N JGSn' , OULDING PERMIT INFO
H a d 279 /C!lI GNvice eoA Svc 7
r M i LICENSED CONTRACTOR'S DECLARATION
z o - I nmebr.rfimm wt I w licensed under pravisims arcn,pan 9(mmmereNg Job Description
F=C� with Section 1000).(Division 3 of the Buxireaand Proftentux Conte,and my license is` O
Uanee Lic.. , S-20J
O c Da« Conuecwr
nin
F.L,
0.1 ARCHrIELTS DECLARATION
I unders«w my Deans shell be us i u publi<rcmNs ^/
wce
Ucm nd Profeuimal
w_y OWNER-BUILDER DECLARATION
t-z a I hereby&Rmm Jut I sen exempt from she Convector's License Law fm the
Ofollowing renin(Sasian 7031.5.Bmiress and PmBseions Cade:MY city as cranny
i 3 which rcquuaa Dermic u conswn,alar,improve,demolish,m«pair any awcturc Sq. Ft. Floor Area Valuation
prim m as issmnea,also regmres the applicant forsmh permit o file.signed eat«mem
thathelslicemedporsuantm Nepmvisionsof Ne Cannatalslic mLew(CMpa9
he is
Mlegolnc.empaPmAny"also.of APN Number Occupancy Type
Sdust,he is 31.5 b therefrom W as burs Tor the alleged exemption Any violaiutr of OS S P Y YP
Batton thews five
any applicant ren a permit subjects the applicant m e civil penalty of
nit mo«Jun Evc hure.rcd dollen(S500).
❑Lasownerk,ed prupeny,mmy.intendedwimwagnbthev Bale cpmpenaatiw, Required Inspections
will Prfewmk,endthe ehcontisnmi Licensesuffered Law
My to an owner
ers
aM property
who Code:TW over drama Limnse taw does cwt apply so lf owrcr of
progeny who hieda or Improver de,such i n who does such wmk himself or Jed for
his own employees,provided Nat such mens I.mm«are nil mended m plened for
WeIf.hower s,car will have
en of proving
gthat hewithinion dearyesurimprovetim.Jc ( .�
Ifs ile).will here Nc burden of proving that W did not build or improve for par. /v
pose of.mower.)
1,a of drect leoPeny.an ture.vnal convecting with:)"a Ceono-amnxs i.
construct the project"Iy u, 6,Future.aM Professions Cade:)T1s.Contractor's Li� 01
eat..taw does rxu applyje ts awrer of progeny,wed hd m improves C.�eoo,ate.
wbo comm..far such panjau with a conuacmrfsl licensed pursmm w she Contmrols
License law.
❑1 em<aemq order Sa. .B&P C fm this realm
Owner
Dare
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following lederaime:
er
I he eM will mairmin.Callfiau ofComrnt to ulFlmuu fm Workers Comp:m
sation,as provided for by Section 3100 of Ne Leben Cade,fm the paf..of the
work for which this permit is issued.
r-I I have W will maintain Warkafs Compensation In,nseree,no mequued by Section
310aofthe LeWl Code,for
N e peAormarrof Ne work Tor which this permit is isaued.
My Workcr' .one notion 1 urea carries and Policy nm
Carrier. �PoIicYNo.: 't.=�1&4�,,Lao I
CERTIFICATE OF E.EMMON FROM WORKERS'
COMPENSATION INSURANCE
obis umim need nil he mmptmed!d the pcmJt ie future hundred"I.(SM)
Or less.)
I cenify ttit in the peRorrmwce of the work for which this permit is issued,I shill
not employ any person in any manner an as to become mbjat to Ne Wmi,an'ComPmn
union laws of California.Da«
Applicant
NOTICE TO APPLICANT:If,after malting this Cmifzc*w of Exemption,you should
haeme subject to In,Workcls Compensation provisions of the L.Wr Code. no most
Forthwith comply with such provisions ar this permit shall bo demand rooked.
CONSTRUCTION LENDING AGENCY
Q I Wreby Nn that Nem is.mmatmetiop landingagency fonhepesfumua.of -
z the work for which Nis Permit is issued(Sec.3091,Cr,C.)
LeM,ex Name
a > LenSteaAddress
Lg7 1 oenify Nat I have read Nis appllcatioo and swe that the above mfomotion is
IL correct.I agree to comply with all city Dd county maimumne"scale laws messing m
zbuilding comvacm..and hereby aUWH«r.pesenwives of Nis city to a.,upon ft
Li O a havememiWedproKnY ren inspection purpoax.
W f•t (We)ogre m i ,indemnify and kaP harmless Jc CitY of Cupcnim a8amn
3 U linbilitiecjudgmcm c uenJ cxpen«a which may in any way acrve agalnxt said Ciry
} W is conaquenec of ung of Nis permit.
(� A. APPLICANT '1. STANUB ANU WILL COMPLY WITH ALL.NDN�POINT
V z BOUNCER :I IONS,
— Sigtuwreo Appllant2Convatm +« J //J�O Ce—
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm Wilding acupam.wreor handle haaardous mauial Re-roofs
m defined by the Cupertino Muvcipal Code,CheWs 9.12,nod the Health ere.Safety Type of Roof
Code,Section 25532(.)? YP
❑Yes
Wllthe applicantor futureh ing mcupam use cquipncm or do vices which All roofs shall be inspected prior to any roofing material being
.mi,heardom ab conumimnu .fined bythe Bay Asa AE Quality Managemem installed. If a roof is installed without first obtaining an inspection
a'^a° I agree to remove all new materials for inspection. Applicant
00 ❑Yes No
Iheve reed dwsmamdal> a under Chapter 6.95 of We cath- understands and will comply with all non point source regulations.
rc arse
rami.Ninth&Saf e.Section,255x5,25533 and 2553x.I uMmund Net if the,
"Ringdas Yh_.oaant.Nair ismyrapon'bilirywretify Naacupet
of Ne«qui« hh must be ma poor w iseuence of a Cenifau ppff Ocettpp y.
/1J/DUSignature of Applicant Date
Owner m edam agent r lacts —
All roof coverings to be Class"B"or better
OFFICE