00050026 CITY OF CUPERTINO PERMIT NO.
BUILDING DIVISION PERMIT ' " CONTRACTOR INFORMATION: alp OS002(p
BUI INGADDRFSS: 111 1,, fes,
1^ 0 map or, I�It1/n/ 11 I f /t� ✓ I({/f�/� SANITARY NO. APPLICATION SUBMITTAL DATE
OW! NAM 1a 11W Vi;/W, -1 w�f/�' �'(�'�LV
ll N/C COhTROLp
PHONE: U I+�// I{'l (//�' Q 11�1�\r "
ARCHITECPENGINEER I q a" dI CA f y� r`a , BUILDING PERMIT INFO
��o 510-Zg3-20I2
LICENSED CONTRACTOR'S DECLON
z
o = I nerebr,thrm that l un limitedlimitedends pmvisiaas of Chapter 9(pnr.lrrle.rmg Job Description
ARATI
w withSeclimLW0)of Di ion of the Business soul Professions Coda rod my B«nu is
yS= mfullF, andxlex JJ////��Y //��"L
C C< licepu Lic. �L// -1 l'1��
5 a v Date. Co.:vazmr - �e��q�e f Gf /D �all�� uv
1-u.O a .ARCHITECTS DECLARA
F,✓,. = I understand my plans shall be used as xibbc -
K
i
Licensed Rofessiorol "
_vii OWNER DER DECLARATION
F Z< 1 hereby aRirm that 1 am exempt from the Condos oc License c taw for the • '
$(=C Followingreason.
ermiti ]031.5,Bpaiass and Professions de innaCWe:Any city or county
s.C which rets rom a permit m[nKWet,aper,Improve,demolish,or repair and atmond
3 m Sq. F[:Floor Area aluatio
puthecan,issiersedI dw ,to re,the the applicant(«suchpttmit lofiee,La lshaptert .
(m he is ml,with
punuam to N)provisions 31dtfthe Conuanpre dd prof taw(Chapter r
" (commencing withSenion100p)ofDivinionJofNeBusineasmdPvfessionsCnde)m APN
NNumber - OccupancyT e
at he is exempt Ihertrrom and the basis for the alleged exemption.Any violation of Yp
section 1031.5 by my applicant for a permit subjects the applicanuo a civil penalty of -
pt more Nan five Wodred dollars(1500).
1,an owner or Ne property,or my employees with wages a their sole corepemafion. Required Inspections -
will do the work,and Ihe atsaturt is not intended or offered To sale(Sec.1044,Business
and Professions Cade:The Contractors Limum law docs not apply to an owrrr of
property who builds or improves thereon,and who does such work himself or 0vough
his own employees,provided them such improvements ane ooh intended or offered for
ade:lfluxi,in
enthe Wildogorimpmvconemissoldwitbinoro yrorofcorepletim.the -
rW ilder will have the burden of proving that he did not build or improve for pur-
Put.of
1,u owner of Ne Property,am cxdmivdY conuwtin8 with laenud<onuactors tom far��yj_yl-a
or.La Ne project apply
.an Business and rttafesdons Code:)The Cooherem.I.i-
whoc law does r such
to m with
water of recommits)
wce Wilds os ant to the thereon,and
who Lace for such projau with a contmdor(s)licensed pursuant the Cpnuador's -
I: l ae law.
" ❑lam exemptunder Sec. .B&PCfor this reason
Owner Date 0
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of Perjury mar of the following dee Watiom:
❑ ro
Inavemd will maintain a Certificate or Conant to self-mmumfmWorker'aCompen-
tion,u pvided for by Section 3100 of the Labor Cade,for the perfomuttce of the
k fee which this permit is timid.
0 I have and will maimnin Workers Compensation In mance.as respired by Setstion
/1W m Ch�efa ImC.,Cole,for the parfomuntt of the work for
mwhich
ythis permit is issued.
MY Woh1.111{y1PpRs§{ipn lysurancc carrier mdyolicY VGK g�nl)U�U�A .
Carnet fI C,11(/e'YI
Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
' ('Ibis scctim need not becomplered dthe prmrit is frronc hundred dollar 13100)
or less.) -
I certify Nat in Ne performance of Ne work for which this rmat is iswed,l shall _
not employ any person in my manner m.,in become .bj.to the Workers'Compcn-
sation laws of California.Date -
APPlicant
NOTICE TO APPLICANT.If,afar making this Cri ifcate of Esmmption,you should
him me subject to the Worker Comminution provisions of the Labor Code.you must
(oMwith comply with such provisions or this permit shall he d«med revoked.
CONSTRUCTION LENDING AGENCY
O Q Ihereby affirm NV Here is a construction lending agency for the performance of r
Z de work for which this Rmth is issued(Sec.3091,Civ.C.)
2 -
Lenders Name
. a ; larders Address
Lt: 1 certify Nan 1 have orad this application and anal,dant the above information is -
0, CCara..l aper m comply with all city and colmo res and ruts laws scaling no
r7 Z building mmttuctim,end hereby,uthodu«prowmadwspfthis city to enter upon the -
V"C above-memipned property for inspection purposes. -
(r F. (We)agree to save,indemnify and kap harmless the City of Cupertino agdmt
O U liabilities,judgments,mms and e.lism.which may in my wayacmueagalon said City
;aa W n comesueocc of the granting of Nis permit.
0. in
UNDERSTANDS AND WILL COMPLY WITH ALL NON.POI T _
�' SOURCE REGUTATI N5. '
z ti - 4/moi oo
Sigromreof Al emUCont nor Date
DOLS MATERIALS DISCLOSURE
Will them icmt or future building«cm.mil stmtm handle neaardous maenad Re-roots
as defined by the Cupcnim Municipal Code,Chapter 912•and the Health and Safety T e of Roof "
Cade,section 2353200? - Yp
[_1 yea XNo
Will the applicant ft buildinget p t eesuipmeniordevices which
.All roofs shall be inspected prior to an roofing material being.
mit hand .n mm tsa defumA by thea y Ares An Quality Mm,gement installedAf a roof is installed without first obtaining an inspection
I a ree to remove all new materials for inspection. Applicant
District?
Y<ssa e n pphp
Inaye read the haadn;mal as�premm made,chaa 6e5nfN Gdi- understands and will comply with all non point source regulations.
from Health&Safety Code.Sections 235%,M533 and 235%.1 ondcrsund that if the
building does not curet fly havea Innm1that at it is my responsibility m nosily e �
t f-
Signature
oftheremno 'ch must is mut primto uamme ofa Continuum,M co«c
Signature of Pelican Date
(honer or onaedage Dau All roof coverings to be Class`B"or better '
OFFICE