00050044 -- - - -- - -------
CITY OF CUPERTINOPERMITNO.
BUILDING DIVISION PERMIT ACTZ ORMATI ' [7/`/'7LI
LDING ADDRESS: ,. O`er/j�/O �y/�D0 /
rn SANITARY NO. , APPLICATIONSUBMITFALDATE
OWN�{'S .N/C CONTROL# —v
PHONE (LJ-• 5J CA- 95/5j _ El -
ARCHITE T/ENG] EER �/7Ql q/, ��✓c O BULDING PERMIT INFO
FGU /
LICENSED CONTRACTOR'S DECLARATION
Z=L I hereby amort Nm 1 am Rmnud under provisions of Chapter 9(commencing Job Description
with Section70W)of Division 3 clubs Businessand Professions Cade,and my license is �—
z Q in fol]force and effect. d'
umame].aa omm
3 LL
Date cmnwctor
1..�O' ARCHr1ECTS DECLARATION /
W y 1 understand my plans shill be usM as Public recoils
c.i O Licensed Prufemimul
w OWNER BUILDER DECLARATION �
r Z S I thereby amrm that 1 am exempt n
pt from the Cometors License thaw for the f 4 'f``
4_6
h`m following' rca (Section 703 IS.Business and Profeasions Code:Any city as county
L 3_ whirl,ox tiro a Penni,to mummer.dies,improve,demolish,or repair any swctme Sq. Ft. FloorArea Valuation
prim to its i"umm,also requires do applicant for such permit to file.signed statement
that he is licensed purmu tm thepnovisiom of the Contractors Us..law(CMpter9 -
(catheisingwitnseiion7lwolth basimn3 orNeeedZenhim,Aaianxc y APNffb� Occu�an= e
Wt he is exempt Nasfrom and the buffs for Ne alleged cxcmption.An .tion of �J ,Z, y
Section 7031.5 by any applicant for a pert,subjects the applicant t civil penalty t,
nm more Nan rive hods d dollen(5500).
0I,avowamofdupropeny,mmyempbymswiNwgamftirmlccompe n. Re ul ns' '
will dothe work,and thestrucmrt ism intondcdoroRertd for We(Sec.70rr,Buri
and Forfeitures Cade:The Contractor's License law does nm apply to an owner a
property who builds or improves tenon,and who does such work himself oe through
his own oeot the Provided Net such improvements are not intended m pRered for
comer-twde If. owe,will h Wilding w improvement is sold did an Wild
m completion for d- _
-Wilder,will have the burden of provin6 that he did war build nor improve res pm-
1,u owes of the property,em exclusively mmo-ectin6 with IkensM cono-acton to - -�
construct Coes our (Sae](arowner of and
rtywhoWiCade:)The CaduceisLi-
Li-
music law does ton applyje an coos of progeny who sedan or immoshe Corton.and
who contracts Lace for such projectspiN a comnemr(i)licensed punuenno the Conoutors l•/�
License Law.
[Ilam<xcmq unau Ba. - .B&PCfor Nis neasrn - -
Owmr, Date
WORKER'S COMPENSATION DECLARATION u
737W.f
the emnn under penalty of pvjury ox r!du fmllmwin8 dxluatimm:
aMwil]mdnWn.Cenificmeaf Cons ttoself-insumfmWorkersCompen-
provided for by Secure 3700 of the Labor Code,for the performance of the t
which this pm ,is issued.
e noun will maintain Workers Compensation Incurrence,as required by Section
Ne labor Cade,fm the performanceofthe work for which this penin,it iuuW.
em sed Polity ben T�S. /'�. PolicynTITIIC-ATE OF EXEMPTION FROM WORKERS'COMPENSATION INSURANCE
hisaction nod nm be compleind ifthe pemtit ix formic hundreddollda(5100)-
renifyNatinthepurrin sof the work for which this Purim is ismad.lchill
not oY enY Peron N enY mentor m as to mmmeawbj«t w the warren'Compcn-
mnlawro(ffordia,Date
APWicm, - �LP -
OIICE MA ,TcArkf,aRm M&ng dfN CeniBcam of Exemption,you should
become subject to the Wmkero Campwtimn provision of Nc Labor Cade,you must
forthwith Comply with such Provisions or this permit shall be d«med mvekM.
CONSTRUCTION LENDING AGENCY z
O 0 I hereby affirm now Nen is.mounted a lending agency fee the pu orrom a of
z =
the,work for which Nis permit is issued(Sea.3097,Civ,C.) e .
Ey Lenders Name
ai > lenders Address
L.7 E I Gentry the,I have mad Nle npplicalkno and suite that the ahmve information Is
96 z rmreen.I agree to comply with all city end county odinanm and star;laws mbdng to - -
building construction,and hereby incriminateincriminaterepresentatives of this city to enter upon thus Othus
ebovcmemimed property for inspired.punpnscs. -
:a. E„ (We)agree to use.indemnify and keep luumleat Ne City of Cuaninm against -
O () ludlitics.judgments.cents and expenses which may in my way.cane against said City .
�..
Win consequence of the ..c,of this penmi,.
APPLICANT UNDF,RSTANDI AND WILL COMPLY WITH ALL NON-POINT
.� SO CEy9 ULATION3.
ig,�m re'�d Appli JConaa7 4Y Date _
HAZARDOUS MATERIALS DISCLOSURE
Wilby he Currantm Muni;pal odec Chapter
bindle haxudoaamaurid Re-roofs
as defined by the Cupertino Municipal Code,Chapmr 9.12,end the HedN and Safety s /
' eMe,Section zs53z(e)+' � f Roof .
❑Yet [I No
� ,.•.
Will the applicant or future Wilding excupent use equipment or dcsims which AIIAII roofs slTa inspected prior to an top material being
emit bvudmer air cmnuml..as.cultured by Ne Be,Ana Air Quality Management installed. If a roc is d with first obtaining an inspection
Y� C]No
I agree to remove all new m ins ectiom Applicant
Ihavc read the heaardous rtutende nmuinmmm under Chapter 6.95 of Ne Cali- Understands and will co y with all non p rce regulations. '
fomu H..16&Safety Codc,Sectims ZS(Xi,25533 and 2S53r.1 understand!,het if the
building dila currently have a omen.that it is my responsibility w notify Ne ampant
of }Is,E u hest trot pd ,o issuuee o(.Cm�Ticalfs[gfc
/��� f 9 qD
Signature of• ;cunt Date
fhvmr oiautho�i c nog t Dau '
All roof coverings to be Class`H'or better
OFFICE
a